Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

Diagnosis

  • 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]

  • 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]

  • 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]

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

  • 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]

  • 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[13] class III–IV] or has had an MI within the past month) or

    • an angiotensin II receptor antagonist (ARB) licensed for heart failure[14] (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[15] and has moderate to severe heart failure [NYHA class III–IV]) [new 2010]

Rehabilitation

  • 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[16].

    • Include a psychological and educational component in the programme.

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

Monitoring

  • 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[17]. [2003, amended 2010]

  • 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]

Discharge planning

  • 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]



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

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

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

[16] 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.

[17] 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.

  • National Institute for Health and Care Excellence (NICE)