Update information

September 2018

This guideline updates and replaces NICE clinical guideline 108 (published August 2010). NICE clinical guideline 108 updated and replaced NICE clinical guideline 5 (published July 2003).

Recommendations are marked as [2018], [2016], [2012], [2010], [2010, amended 2018], [2003], [2003, amended 2018] or [2003, amended 2010],

[2018] indicates that the evidence was reviewed and the recommendation added, updated or unchanged in 2018.

[2016] refers to NICE technology appraisal guidance published in 2016.

[2012] refers to NICE technology appraisal guidance published in 2012.

[2010] indicates that the evidence was reviewed in 2010.

[2010, amended 2018] indicates that the evidence was reviewed in 2010 but changes were made to the recommendation wording in 2018 that changed the meaning.

[2003] indicates that the evidence was reviewed in 2003.

[2003, amended 2018] indicates that the evidence was reviewed in 2003 but changes were made to the recommendation wording in 2018 that changed the meaning.

[2003, amended 2010] indicates that the evidence was reviewed in 2003 but changes were made to the recommendation wording in 2010 that changed the meaning.

Recommendations that have been changed

Amended recommendation wording (change to meaning)

Recommendation in 2010 guideline

Recommendation in current guideline

Reason for change

All recommendations referring to heart failure due to left ventricular systolic dysfunction (LVSD).

All recommendations referring to heart failure with reduced ejection fraction.

'Heart failure due to left ventricular systolic dysfunction (LVSD)' has been replaced by 'heart failure with reduced ejection fraction' in line with current terminology and the 2018 guideline scope.

All recommendations referring to aldosterone antagonists.

All recommendations referring to mineralocorticoid receptor antagonists (MRAs).

'Aldosterone antagonists' has been replaced by 'mineralocorticoid receptor antagonists (MRAs') to clarify the function of the receptor, and in line with the 2018 guideline scope.

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]

1.2.7 Be aware that:

  • obesity, African or African-Caribbean family origin, or treatment with diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin II receptor blockers (ARBs) or mineralocorticoid receptor antagonists (MRAs) 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). [2010, amended 2018]

'African or African-Caribbean family origin' has been added because of the high incidence of heart failure with preserved ejection fraction in these populations. Recent evidence shows that NT-proBNP levels are lower in people of west African family origin and are a confounder in the diagnosis of heart failure.

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]

1.2.8 Perform transthoracic echocardiography to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts. [2003, amended 2018]

All transthoracic echocardiography would have doppler 2D as a minimum and it is no longer necessary to specify this.

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

1.2.9 Transthoracic echocardiography should be performed on high-resolution equipment by experienced operators trained to the relevant professional standards. Need and demand for these studies should not compromise quality. [2003, amended 2018]

All transthoracic echocardiography would have doppler 2D as a minimum and it is no longer necessary to specify this.

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]

1.2.11 Consider alternative methods of imaging the heart (for example, radionuclide angiography [multigated acquisition scanning], cardiac MRI or transoesophageal echocardiography) if a poor image is produced by transthoracic echocardiography. [2003, amended 2018]

'Multigated acquisition scanning' has been added to reflect current imaging technology.

All transthoracic echocardiography would have doppler 2D as a minimum and it is no longer necessary to specify this.

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]

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

  • chest X-ray

  • blood tests:

  • renal function profile

  • thyroid function profile

  • liver function profile

  • lipid profile

  • glycosylated haemoglobin (HbA1c)

  • full blood count

  • urinalysis

  • peak flow or spirometry [2010, amended 2018]

Measurement of urea has been deleted because the guideline committee agreed that it is not needed and is not part of renal function profiles in most centres in the UK.

Blood tests for electrolytes, creatinine and eGFR have been grouped together under the term 'renal function profile' because they are provided as a unified set of analyses in the NHS. The term 'profile' is applied to a group of tests (assays). Thus these tests are more accurately described as 'profiles' as they contain multiple individual assays and have replaced thyroid function test, liver function test and lipid measurement.

'Fasting glucose' has been replaced by 'glycosylated haemoglobin (HbA1c)' in line with the NICE guidelines on diabetes.

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

1.4.4 Measure serum sodium and potassium, and assess renal function, before and 1 to 2 weeks after starting an ACE inhibitor, and after each dose increment. [2010, amended 2018]

Measurement of serum urea has been deleted because the guideline committee agreed that it is not needed and is not part of renal function profiles in most centres in the UK.

Measurement of potassium has been added to ensure that monitoring is consistent across treatments.

No recommendation

1.4.6 Once the target or maximum tolerated dose of an ACE inhibitor is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell. [2010, amended 2018]

A recommendation has been added to clarify the timing of monitoring after treatment starts.

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. [new 2010]

1.4.8 Measure serum sodium and potassium, and assess renal function, before and after starting an ARB and after each dose increment. [2010, amended 2018]

Measurement of urea has been deleted because the guideline committee agreed that it is not needed and is not part of renal function profiles in most centres in the UK.

Monitoring for hyperkalaemia has been replaced by potassium measurement for clarity.

No recommendation

1.4.10 Once the target or maximum tolerated dose of an ARB is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell. [2010, amended 2018]

A recommendation has been added to clarify the timing of monitoring after treatment starts.

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]

1.4.13 Introduce beta-blockers in a 'start low, go slow' manner. Assess heart rate and clinical status after each titration. Measure blood pressure before and after each dose increment of a beta-blocker. [2010, amended 2018]

Blood pressure measurement has been clarified and made consistent with other treatments.

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 . [2003, amended 2010]

1.4.26 Digoxin is recommended for worsening or severe heart failure with reduced ejection fraction despite first-line treatment for heart failure .Seek specialist advice before initiating. [2010, amended 2018]

As a result of new evidence the treatment pathway for heart failure with reduced ejection fraction has been amended. Second‑line treatment has been replaced by specialist treatment.

A sentence has been added to clarify that specialist advice should be sought before starting treatment with digoxin.

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]

1.6.2 People who have heart failure with preserved ejection fraction should usually be offered a low to medium dose of loop diuretics (for example, less than 80 mg furosemide per day). People whose heart failure does not respond to this treatment will need further specialist advice. [2003, amended 2018]

The first part of the recommendation has been removed because it is now covered in section 1.1 on team working in the management of heart failure.

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]

1.6.3 Avoid verapamil, diltiazem and short-acting dihydropyridine agents in people who have heart failure with reduced ejection fraction. [2003, amended 2018]

Amlodipine to treat hypertension has been superseded by the NICE guideline on hypertension in adults.

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

1.6.5 Review the need to continue the amiodarone prescription at the 6-monthly clinical review. [2003, amended 2018]

'Regularly' has been replaced by 'at the 6-monthly clinical review' for clarification.

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

1.6.6 Offer people taking amiodarone liver and thyroid function tests, and a review of side effects, as part of their routine 6-monthly clinical review. [2003, amended 2018]

The wording has been amended in line with recommendation 1.6.5.

1.4.1.1 All people with chronic heart failure need 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. [2003, amended 2010]

1.7.1 All people with chronic heart failure need 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

  • an assessment of renal function. [2010, amended 2018]

Measurement of urea has been deleted because the guideline committee agreed that it is not needed and is not part of renal function profiles in most centres in the UK.

ISBN: 978-1-4731-3093-7

  • National Institute for Health and Care Excellence (NICE)