1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

Heart failure due to left ventricular systolic dysfunction (LVSD)

This is caused by impaired left ventricular contraction, and is usually characterised by a reduced left ventricular ejection fraction.

Heart failure with preserved ejection fraction (HFPEF)

This is usually associated with impaired left ventricular relaxation, rather than left ventricular contraction, and is characterised by a normal or preserved left ventricular ejection fraction.

Specialist

Throughout this guideline, the term 'specialist' denotes a physician with subspecialty interest in heart failure (often a consultant cardiologist) who leads a specialist multidisciplinary heart failure team of professionals with appropriate competencies from primary and secondary care. The team will involve, where necessary, other services (such as rehabilitation, tertiary care and palliative care) in the care of individual patients.

Unless otherwise specified, within this guideline specialist assessment or management refers to assessment or management by this specialist multidisciplinary heart failure team. The team will decide who is the most appropriate team member to address a particular clinical problem.

1.1 Diagnosing heart failure

1.1.1 Symptoms, signs and investigations

1.1.1.1 Take a careful and detailed history, and perform a clinical examination and tests to confirm the presence of heart failure. [2010]

1.1.1.2 Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks. [new 2010]

1.1.1.3 Measure serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NTproBNP]) in patients with suspected heart failure without previous MI. [new 2010]

1.1.1.4 Because very high levels of serum natriuretic peptides carry a poor prognosis, refer patients with suspected heart failure and a BNP level above 400 pg/ml (116 pmol/litre) or an NTproBNP level above 2000 pg/ml (236 pmol/litre) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks. [new 2010]

1.1.1.5 Refer patients with suspected heart failure and a BNP level between 100 and 400 pg/ml (29–116 pmol/litre) or an NTproBNP level between 400 and 2000 pg/ml (47–236 pmol/litre) to have transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks. [new 2010]

1.1.1.6 Be aware that:

  • obesity or treatment with diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin II receptor antagonists (ARBs) and aldosterone antagonists can reduce levels of serum natriuretic peptides

  • high levels of serum natriuretic peptides can have causes other than heart failure (for example, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including pulmonary embolism], renal dysfunction [GFR  60 ml/minute], sepsis, chronic obstructive pulmonary disease [COPD], diabetes, age  70 years and cirrhosis of the liver). [new 2010]

1.1.1.7 Perform transthoracic Doppler 2D echocardiography to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts. [2003]

1.1.1.8 Transthoracic Doppler 2D echocardiography should be performed on high-resolution equipment, by experiencedoperators trained to the relevant professional standards. Need and demand for these studies should not compromise quality. [2003]

1.1.1.9 Ensure that those reporting echocardiography are experienced in doing so. [2003]

1.1.1.10 Consider alternative methods of imaging the heart (for example, radionuclide angiography, cardiac magnetic resonance imaging or transoesophageal Doppler 2D echocardiography) when a poor image is produced by transthoracic Doppler 2D echocardiography. [2003]

1.1.1.11 Consider a serum natriuretic peptide test (if not already performed) when heart failure is still suspected after transthoracic Doppler 2D echocardiography has shown a preserved left ventricular ejection fraction. [new 2010]

1.1.1.12 Be aware that:

  • a serum BNP level less than 100 pg/ml (29 pmol/litre) or an NTproBNP level less than 400 pg/ml (47 pmol/litre) in an untreated patient makes a diagnosis of heart failure unlikely

  • the level of serum natriuretic peptide does not differentiate between heart failure due to left ventricular systolic dysfunction and heart failure with preserved left ventricular ejection fraction. [new 2010]

1.1.1.13 Perform an ECG and consider the following tests to evaluate possible aggravating factors and/or alternative diagnoses:

  • chest X-ray

  • blood tests:

    • electrolytes, urea and creatinine

    • eGFR (estimated glomerular filtration rate)

    • thyroid function tests

    • liver function tests

    • fasting lipids

    • fasting glucose

    • full blood count

  • urinalysis

  • peak flow or spirometry. [2003, amended 2010]

1.1.1.14 Try to exclude other disorders that may present in a similar manner. [2003]

1.1.1.15 When a diagnosis of heart failure has been made, assess severity, aetiology, precipitating factors, type of cardiac dysfunction and correctable causes. [new 2010]

1.1.2 Review of existing diagnoses

1.1.2.1 The basis for historical diagnosis of heart failure should be reviewed, and only patients whose diagnosis is confirmed should be managed in accordance with this guideline. [2003]

1.1.2.2 If the diagnosis of heart failure is still suspected, but confirmation of the underlying cardiac abnormality has not occurred, then the patient should have appropriate further investigation. [2003]

1.2 Treating heart failure

1.2.1 Lifestyle

Exercise

See section 1.3, 'Rehabilitation'.

Smoking

1.2.1.1 Patients should be strongly advised not to smoke. Referral to smoking cessation services should be considered. [2003]

Alcohol

1.2.1.2 Patients with alcohol-related heart failure should abstain from drinking alcohol. [2003]

1.2.1.3 Healthcare professionals should discuss alcohol consumption with the patient and tailor their advice appropriately to the clinical circumstances. [2003]

Sexual activity

1.2.1.4 Healthcare professionals should be prepared to broach sensitive issues with patients, such as sexual activity, as these are unlikely to be raised by the patient. [2003]

Vaccination

1.2.1.5 Patients with heart failure should be offered an annual vaccination against influenza. [2003]

1.2.1.6 Patients with heart failure should be offered vaccination against pneumococcal disease (only required once). [2003]

Air travel

1.2.1.7 Air travel will be possible for the majority of patients with heart failure, depending on their clinical condition at the time of travel. [2003]

Driving regulations

1.2.1.8 Large Goods Vehicle and Passenger Carrying Vehicle licence: physicians should be up to date with the latest Driver and Vehicle Licensing Agency guidelines. Check the website for regular updates [2003]

1.2.2 Pharmacological treatment of heart failure

Medicines adherence

For more information refer to 'Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence', NICE clinical guideline 76 (2009).

1.2.2.1 Dosing regimens should be kept as simple as possible, and the healthcare professional should ensure that the patient and carer are fully informed about their medication. [2003]

Heart failure due to left ventricular systolic dysfunction

First-line treatment

See also recommendations 1.2.2.5, 1.2.2.6, 1.2.2.7, 1.2.2.8 and 1.2.2.9 on the use of ACE inhibitors and beta-blockers for first-line treatment. See recommendations 1.2.2.14 and 1.2.2.15 for alternative first-line treatment for patients who are intolerant of ACE inhibitors. See recommendation 1.2.2.13 for alternative first-line treatment for patients who are intolerant of ACE inhibitors and ARBs.

1.2.2.2 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. Use clinical judgement when deciding which drug to start first. [new 2010]

Second-line treatment

See also recommendations 1.2.2.10, 1.2.2.11, 1.2.2.12 and 1.2.2.15 on second-line treatments.

1.2.2.3 Seek specialist advice before offering second-line treatment to patients with heart failure due to left ventricular systolic dysfunction. [new 2010]

1.2.2.4 Seek specialist advice and consider adding one of the following if a patient remains symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker:

  • an aldosterone antagonist licensed for heart failure (especially if the patient has moderate to severe heart failure [NYHA[18] class III–IV] or has had an MI within the past month) or

  • an angiotensin II receptor antagonist (ARB) licensed for heart failure[19] (especially if the patient has mild to moderate heart failure [NYHA class II–III]) or

  • hydralazine in combination with nitrate (especially if the patient is of African or Caribbean origin[20] and has moderate to severe heart failure [NYHA class III–IV]) [new 2010]

ACE inhibitors (first-line treatment)

See also recommendation 1.2.2.2.

1.2.2.5 Start ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target dose is achieved. [2010]

1.2.2.6 Measure serum urea, creatinine, electrolytes and eGFR at initiation of an ACE inhibitor and after each dose increment[21],[22]. [2010]

Beta-blockers (first-line treatment)

See also recommendation 1.2.2.2.

1.2.2.7 Offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including:

  • older adults and

  • patients with:

    • peripheral vascular disease

    • erectile dysfunction

    • diabetes mellitus

    • interstitial pulmonary disease and

    • chronic obstructive pulmonary disease (COPD) without reversibility. [new 2010]

1.2.2.8 Introduce beta-blockers in a 'start low, go slow' manner, and assess heart rate, blood pressure, and clinical status after each titration. [2010]

1.2.2.9 Switch stable patients who are already taking a beta-blocker for a comorbidity (for example, angina or hypertension), and who develop heart failure due to left ventricular systolic dysfunction, to a beta-blocker licensed for heart failure. [new 2010]

Aldosterone antagonists (second-line treatment)

See also recommendations 1.2.2.3 and 1.2.2.4.

1.2.2.10 In patients with heart failure due to left ventricular systolic dysfunction who are taking aldosterone antagonists, closely monitor potassium and creatinine levels, and eGFR. Seek specialist advice if the patient develops hyperkalaemia or renal function deteriorates[22]. [new 2010]

1.2.2.11 For patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment should be initiated within 3–14 days of the MI, preferably after ACE inhibitor therapy. (This recommendation is from MI: secondary prevention, NICE clinical guideline 48.) [2007]

1.2.2.12 Patients who have recently had an acute MI and have clinical heart failure and left ventricular systolic dysfunction, but who are already being treated with an aldosterone antagonist for a concomitant condition (for example, chronic heart failure), should continue with the aldosterone antagonist or an alternative, licensed for early post-MI treatment. (This recommendation is from 'MI: secondary prevention', NICE clinical guideline 48.) [2007]

Hydralazine in combination with nitrate (alternative first-line treatment)

See recommendations 1.2.2.3 and 1.2.2.4 for the use of hydralazine in combination with nitrate as second-line treatment.

1.2.2.13 Seek specialist advice and consider hydralazine in combination with nitrate for patients with heart failure due to left ventricular systolic dysfunction who are intolerant of ACE inhibitors and ARBs. [new 2010]

Angiotensin II receptor antagonists (second-line or alternative first-line treatment)

See also recommendations 1.2.2.3 and 1.2.2.4 for the use of ARBs as second-line treatment.

1.2.2.14 Consider an ARB licensed for heart failure as an alternative to an ACE inhibitor for patients with heart failure due to left ventricular systolicdysfunction who have intolerable side effects with ACE inhibitors. [new 2010]

1.2.2.15 Monitor serum urea, electrolytes, creatinine and eGFR for signs of renal impairment or hyperkalaemia in patients with heart failure who are taking an ARB.[23],[22][new 2010]

Digoxin

1.2.2.16 Digoxin is recommended for:

  • worsening or severe heart failure due to left ventricular systolic dysfunction despite first- and second-line treatment for heart failure[24]. [2003, amended 2010]

All types of heart failure

Diuretics

1.2.2.17 Diuretics should be routinely used for the relief of congestive symptoms and fluid retention in patients with heart failure, and titrated (up and down) according to need following the initiation of subsequent heart failure therapies. [2003]

1.2.2.18 The diagnosis and treatment of heart failure with preserved ejection fraction should be made by a specialist, and other conditions that present in a similar way may need to be considered. Patients in whom this diagnosis has been made should usually be treated with a low to medium dose of loop diuretics (for example, less than 80 mg furosemide per day). Patients who do not respond to this treatment will require further specialist advice. [2003]

Calcium channel blockers

1.2.2.19 Amlodipine should be considered for the treatment of comorbid hypertension and/or angina in patients with heart failure, but verapamil, diltiazem or short-acting dihydropyridine agents should be avoided. [2003]

Amiodarone

1.2.2.20 The decision to prescribe amiodarone should be made in consultation with a specialist. [2003]

1.2.2.21 The need to continue the amiodarone prescription should be reviewed regularly. [2003]

1.2.2.22 Patients taking amiodarone should have a routine 6-monthly clinical review, including liver and thyroid function test, and including a review of side effects. [2003]

Anticoagulants[24]

1.2.2.23 In patients with heart failure in sinus rhythm, anticoagulation should be considered for those with a history of thromboembolism, left ventricular aneurysm, or intracardiac thrombus. [2003]

Aspirin

1.2.2.24 Aspirin (75–150 mg once daily) should be prescribed for patients with the combination of heart failure and atherosclerotic arterial disease (including coronary heart disease). [2003]

Inotropic agents

1.2.2.25 Intravenous inotropic agents (such as dobutamine, milrinone or enoximone) should only be considered for the short-term treatment of acute decompensation of chronic heart failure. This will require specialist advice. [2003]

Heart failure due to valve disease

1.2.2.26 Patients with heart failure due to valve disease should be referred for specialist assessment and advice regarding follow-up. [2003]

1.2.2.27 ACE inhibitor therapy should not be initiated in a patient with a clinical suspicion of haemodynamically significant valve disease, until the valve disease has been assessed by a specialist. [2003]

General

Age

1.2.2.28 The management of heart failure should be determined by clinical criteria, irrespective of the age of the patient. [2003]

1.2.2.29 Tolerance of drugs may be lower and side effects require closer and more frequent monitoring in older patients. [2003]

Gender

1.2.2.30 The principles of pharmacological management of heart failure should be the same for men and women. [2003]

1.2.2.31 In women of reproductive age who have heart failure, contraception and pregnancy should be discussed. If pregnancy is being considered or occurs, specialist advice should be sought. Subsequently, specialist care should be shared between the cardiologist and obstetrician. [2003]

1.2.2.32 The potential teratogenic effects of drugs should be considered. [2003]

Comorbidities

1.2.2.33 Manage comorbidities according to:

  • 'Hypertension', NICE clinical guideline 34 (replaced by 'Hypertension' [NICE clinical guideline 127])

  • 'MI: secondary prevention', NICE clinical guideline 48

  • 'Type 2 diabetes', NICE clinical guideline 87

  • and other relevant NICE guidance.

    This is particularly important in heart failure with preserved ejection fraction. [new 2010]

1.2.3 Invasive procedures

Coronary revascularisation

1.2.3.1 Coronary revascularisation should not be routinely considered in patients with heart failure due to systolic left ventricular impairment, unless they have refractory angina. [2003]

Cardiac transplantation

1.2.3.2 Specialist referral for transplantation should be considered in patients with severe refractory symptoms or refractory cardiogenic shock. [2003]

Cardiac resynchonisation therapy

Refer to 'Cardiac resynchronisation therapy for the treatment of heart failure'. (NICE technology appraisal guidance 120 [2007]). Please refer to the NICE website for updates on the review status of this appraisal.

Implantable cardioverter defibrillators

Refer to 'Implantable cardioverter defibrillators for arrhythmias' (NICE technology appraisal guidance 95 [2006]). Please refer to the NICE website for updates on the review status of this appraisal.

1.3 Rehabilitation

1.3.1.1 Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure.

  • Ensure the patient is stable and does not have a condition or device that would preclude an exercise-based rehabilitation programme[25].

  • Include a psychological and educational component in the programme.

  • The programme may be incorporated within an existing cardiac rehabilitation programme. [new 2010]

1.4 Monitoring

1.4.1 Clinical review

1.4.1.1 All patients with chronic heart failure require monitoring. This monitoring should include:

  • a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status

  • a review of medication, including need for changes and possible side effects

  • serum urea, electrolytes, creatinine and eGFR[26]. [2003, amended 2010]

1.4.1.2 More detailed monitoring will be required if the patient has significant comorbidity or if their condition has deteriorated since the previous review. [2003]

1.4.1.3 The frequency of monitoring should depend on the clinical status and stability of the patient. The monitoring interval should be short (days to 2 weeks) if the clinical condition or medication has changed, but is required at least 6-monthly for stable patients with proven heart failure. [2003]

1.4.1.4 Patients who wish to be involved in monitoring of their condition should be provided with sufficient education and support from their healthcare professional to do this, with clear guidelines as to what to do in the event of deterioration. [2003]

1.4.1.5 When a patient is admitted to hospital because of heart failure, seek advice on their management plan from a specialist in heart failure. [new 2010]

1.4.2 Serum digoxin

1.4.2.1 Routine monitoring of serum digoxin concentrations is not recommended. A digoxin concentration measured within 8–12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non-adherence. [2003]

1.4.2.2 The serum digoxin concentration should be interpreted in the clinical context as toxicity may occur even when the concentration is within the 'therapeutic range'. [2003].

1.4.3 Serum natriuretic peptides

1.4.3.1 Consider specialist monitoring of serum natriuretic peptides in some patients (for example, those in whom uptitration is problematic or those who have been admitted to hospital). [new 2010]

1.5 Referral and approach to care

1.5.1 Referral for more specialist advice

1.5.1.1 Refer patients to the specialist multidisciplinary heart failure team for:

  • the initial diagnosis of heart failure and

  • the management of:

    • severe heart failure (NYHA class IV)

    • heart failure that does not respond to treatment

    • heart failure that can no longer be managed effectively in the home setting. [new 2010]

1.5.2 Discharge planning

1.5.2.1 Patients with heart failure should generally be discharged from hospital only when their clinical condition is stable and the management plan is optimised. Timing of discharge should take into account patient and carer wishes, and the level of care and support that can be provided in the community. [2003]

1.5.2.2 The primary care team, patient and carer must be aware of the management plan. [2003]

1.5.2.3 Clear instructions should be given as to how the patient/carer can access advice, particularly in the high-risk period immediately following discharge. [2003]

1.5.3 Multidisciplinary team approach to heart failure management

1.5.3.1 Heart failure care should be delivered by a multidisciplinary team with an integrated approach across the healthcare community. [2003]

1.5.4 Non-NHS agencies

1.5.4.1 Standard one of the 'National service framework for older people' states: 'social care services will not use age in their eligibility criteria or policies to restrict access to available services'. This applies to patients with heart failure. (See Department of Health) [2003]

1.5.4.2 Management plans for patients with heart failure should be discussed with non-NHS agencies where they are involved in or responsible for the care of a person with heart failure. [2003]

1.5.4.3 The principles of pharmacological management for a patient cared for in a non-NHS institution should be similar to those for any other patient with heart failure. [2003]

1.5.4.4 The education needs of non-NHS agency carers should be considered. [2003]

1.5.5 Communication

1.5.5.1 Good communication between healthcare professionals and patients and carers is essential for the best management of heart failure. [2003]

1.5.5.2 Guidelines for good communication:

  • Listen to patients and respect their views and beliefs.

  • Give patients the information they ask for or need about their condition, its treatment and prognosis, in a way they can understand including information about any serious side effects of drugs to be prescribed.

  • Provide the most important information first.

  • Explain how each item will affect patients personally.

  • Present information in separate categories.

  • Make advice specific, detailed and concrete.

  • Use words the patients will understand; confirm understanding by questions; define unfamiliar words; write down key words; draw diagrams and keep a copy in the medical notes.

  • Repeat the information using the same words each time.

  • Prepare material, written or taped, to back up handwritten notes.

  • Share information with patients' partners, close relatives or carers if they ask you to do so. When patients cannot indicate their consent for such sharing of information, it is advisable to share the information that those close to the patient need or want to know, except where you have reason to believe that the patient would object if able to do so. [2003]

1.5.5.3 The content, style and timing of information provision should be tailored to the needs of the individual patient. [2003]

1.5.5.4 Healthcare professionals should assess cognitive ability when sharing information. [2003]

1.5.5.5 Carers and relatives of patients who are cognitively impaired should be made aware of treatment regimes for the patients they care for and be encouraged to identify any need for clinical support. [2003]

1.5.5.6 Management of heart failure should be seen as a shared responsibility between patient and healthcare professional. [2003]

1.5.5.7 Unless specifically excluded by the patient, carers and relatives should be involved in the management of the patient, particularly where the patient cannot look after him- or herself. [2003]

1.5.6 Prognosis

1.5.6.1 Prognosis should be discussed with patients and carers in a sensitive, open and honest manner. [2003]

1.5.7 Support groups

1.5.7.1 Healthcare professionals should be aware of local cardiac support networks and provide this information to patients and carers. [2003]

1.5.8 Anxiety and depression

1.5.8.1 The diagnosis of depression should be considered in all patients with heart failure. [2003]

1.5.8.2 Where depression is likely to have been precipitated by heart failure symptoms then reassessment of psychological status should be undertaken once the physical condition has stabilised following treatment for heart failure. If the symptoms have improved no further specific treatment for depression is required. [2003]

1.5.8.3 Where it is apparent that depression is co-existing with heart failure, then the patient should be treated for depression in line with 'Depression: the treatment and management of depression in adults' (NICE clinical guideline 90) and 'Depression in adults with a chronic physical health problem: treatment and management' (NICE clinical guideline 91). [2003]

1.5.8.4 For patients with heart failure, the potential risks and benefits of drug therapies for depression should be considered carefully. [2003]

1.5.8.5 Patients with heart failure should consult a healthcare professional before using over-the-counter therapies for depression such as St John's wort (Hypericum perforatum). Healthcare professionals should be aware of the potential interaction with prescribed medication, and always ask about self-medication, including the use of herbal products. [2003]

1.5.9 End of life

1.5.9.1 Issues of sudden death and living with uncertainty are pertinent to all patients with heart failure. The opportunity to discuss these issues should be available at all stages of care. [2003]

1.5.9.2 The palliative needs of patients and carers should be identified, assessed and managed at the earliest opportunity. [2003]

1.5.9.3 Patients with heart failure and their carers should have access to professionals with palliative care skills within the heart failure team. [2003]



[18] The New York Heart Association classification of heart failure.

[19] Not all ARBs are licensed for use in heart failure in combination with ACE inhibitors.

[20] This does not include mixed race. For more information see the full guideline

[21] For practical recommendations on treatment with ACE inhibitors see 'Chronic kidney disease', NICE clinical guideline 73.

[22] For more information see appendix D.

[23] For practical recommendations on treatment with ARBs see 'Chronic kidney disease', NICE clinical guideline 73

[24] See 'Atrial fibrillation', NICE clinical guideline 36 for recommendations on the use of digoxin in patients with atrial fibrillation.

[25] The conditions and devices that may preclude an exercise-based rehabilitation programme include: uncontrolled ventricular response to atrial fibrillation, uncontrolled hypertension, and high-energy pacing devices set to be activated at rates likely to be achieved during exercise.

[26] This is a minimum. Patients with comorbidities or co-prescribed medications will require further monitoring. Monitoring serum potassium is particularly important if a patient is taking digoxin or an aldosterone antagonist.

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