2 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

2.1 Dopamine

In people with acute heart failure, congestion and worsening renal function, does the addition of low‑dose dopamine to standard therapy lead to greater diuresis and renal protection compared with adding placebo to standard therapy?

Why this is important

A randomised controlled trial should be conducted to investigate whether the addition of low‑dose dopamine to standard therapy leads to more clinically and cost effective decongestion in people admitted to hospital for treatment of decompensated heart failure. The study should aim to investigate the diuretic effect of dopamine as well as effects on renal function.

One of the most common and difficult to manage problems arising during the initial treatment of people with acute heart failure is an inadequate response to intravenous diuretic therapy (that is, failure to relieve congestion), which is often associated with worsening renal function. This combination frequently leads to a prolonged inpatient stay and is associated with higher inpatient mortality rates and higher post‑discharge mortality and re‑admission rates. The best treatment for this combination of problems is unknown. However, theoretical and experimental evidence indicates that low‑dose dopamine may improve renal blood flow, as well as enhance sodium and water excretion. Clinical trials have not yet resolved whether in some patients, the use of low‑dose dopamine actually results in improved decongestion and shorter hospital stays.

2.2 Thiazide

In people with acute heart failure and persistent congestion, does the addition of a thiazide diuretic to standard therapy lead to greater diuresis compared with adding placebo to standard therapy?

Why this is important

A randomised controlled trial should be conducted to investigate whether the addition of a thiazide diuretic to standard therapy leads to more clinically and cost effective decongestion in people admitted to hospital for treatment of decompensated heart failure.

One of the most common and difficult to manage problems arising during the initial treatment of people with acute heart failure is an inadequate response to intravenous diuretic therapy. This frequently leads to a prolonged inpatient stay and is associated with higher inpatient mortality and higher post‑discharge mortality and re‑admission rates. The best treatment for this problem is unknown. However, there is some inconsistent and non‑robust evidence that addition of a thiazide or thiazide‑like diuretic (metolazone) may be beneficial. The proposed study would aim to resolve this uncertainty and guide the management of a difficult clinical problem.

2.3 Intra‑aortic balloon counter‑pulsation

In people with acute heart failure and hypoperfusion syndrome, is the use of intra‑aortic balloon counter‑pulsation pump (IABP) better than the use of intravenous inotropes?

Why this is important

A randomised controlled trial should be conducted in people with decompensated heart failure due to left ventricular systolic dysfunction and systemic hypoperfusion comparing the use of IABP with the use of inotropes/vasopressors. This would determine which strategy is more clinically and cost effective in this cohort.

IABP is used in the hospital setting as an adjuvant in people with critical coronary ischaemia and in people with mechanical complications of acute myocardial infarction. It has also been used in people who develop cardiogenic shock after acute myocardial infarction. However, it is uncertain whether it can provide clinical benefit in the critically unwell patients with acute heart failure due to left ventricular systolic dysfunction and systemic hypoperfusion.

2.4 Ultrafiltration

In people with decompensated heart failure, fluid congestion and diuretic resistance, does ultrafiltration lead to more rapid and effective decongestion compared with continuing diuretic treatment?

Why this is important

A randomised controlled trial should be undertaken to determine whether ultrafiltration is more clinically and cost effective than conventional diuretic therapy for people admitted to hospital with decompensated heart failure. The study should not only investigate several clinical outcomes but also consider the impact of treatments on quality of life and provide data on safety.

People who have fluid retention that is resistant to conventional diuretic therapy, with or without renal dysfunction, make up a high proportion of hospital admissions due to heart failure. Such admissions are often prolonged and therefore have important budgetary implications for the NHS. The few, relatively small scale, randomised trials of ultrafiltration performed so far have been conducted in healthcare settings very different from the UK, with less fluid retention than is usually seen in UK practice, and where length of stay is usually much shorter than in UK (and European) practice. Although technically feasible, the evidence for benefit on heart failure outcomes is inconsistent and difficult to generalise to UK practice. Therefore a UK‑based study of sufficient quality is needed.

  • National Institute for Health and Care Excellence (NICE)