Chronic Heart Failure- NICE guidance

Heart failure is complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood ( Yancy et al 2013 )

Ejection fraction- Definition of reduced EF varies in clinical trials between LVEF of <= 35 to 40 %
 HF with reduced ejection fraction ( HF-REF )
 HF with preserved EF – nearly 1/2 of people with HF have preserved LVEF on echo Time – course Acute HF may be a new presentation of HF or may be deterioration or decompensation in a person with existing HF
 Chronic- no agreed definition. Stable HF used to describe a person with treated HF and symptoms which are unchanged for at-least a month

Careful and detailed 
history and perform clinical examination and tests to confirm the presence of heart failure CXR Bloods
○ renal profile
○ Lipid profile
○ Hba1c
○ FBC Urinalysis Peak flow and spirometry ECG and rest to evaluate possible aggravating 
factors and / or alternative diagnosis

Measure NT-proBNP in people with suspected heart failure above 2000 ng/L or
236 pmol/L or Refer urgently for specialist assessment and Transthoracic echocardiography within 2 weeks 400 and 2000 ng/L
47 to 236 pmol/L Specialist assessment and echocardiography
 within 6 weeks Less than 400 mg/ L
47 pmol/L in an untreated person Diagnosis unlikely
Review for alternative causes and discuss with a physician with subspeciality training in HF if you 
are still concerned

Points to note about BNPObesity or African-Carribean family origin or treatment with diuretics , ACE inhibitors , beta blockers , ARBs or MRAs can reduce levels of serum natriuretic peptide
 High levels of serum natriuretic peptide can have causes other than heart failure for eg

○ age over 70 yrs
○ ischaemia
○ tachycardia
○ right ventricular overload
○ hypoxaemia incl PE
○ renal dysfunction (eGFR < 60 )
○ sepsis
○ diabetes
○ liver cirrhosis


should be used routinely for the relief of congestive symptoms and fluid retention and titrated according to need following the initiation of subsequent HF therapies
 Calcium channel blockers

Avoid verapamil , diltiazem and short acting dihydropyridine agents in people with reduced ejection fraction

○ Discuss with a specialist to make the decision 
( before prescribing )
○ Review the need to continue 6 monthly
○ Offer LFT and TFT and a review of SEs as
 part of routine 6 monthly clinical review

Those with AF + HF -follow the NICE guidance 
on AF
Beware of the affects of impaired renal and liver function on AC therapies
HF + SR → anticoagulation should be be 
considered if h/o thromboembolism , left ventricular aneurysm or intracardiac thrombus

Offer low to medium dose of loop diuretics eg
Furosemide at less than 80 mg / D
 If they fail to respond to this → refer for specialist advice

ACE inihibitors○ Do not offer if clinical suspicion of haemodynamically sig valve disease until the valve disease has been assessed by a specialist

○ start at a low dose and titrate upwards ever 2 weeks until the target max tolerated dose is reached

○ Check Na , K+ and renal function before and 1-2 weeks after starting Rx and after each dose increment and also check BP

○ Once the target max tolerated dose of an ACEi is reached monitor monthly for 3 months and then atleast every 6 M and at any time the person becomes acutely unwell

Beta blockers Do not withhold treatment with a beta blocker solely because of
○ age
○ peripheral vascular disease
○ erectile dysfunction
○ diabetes
○ interstitial pulmonary disease
 Start in a start low go slow manner
Assess HR and clinical status after each titration and measure BP after each increment
 Switch people whose condition is stable and who are already taking a beta blocker for a comorbidity ( for eg angina or hypertension ) and who develop HF with ↓ EF to a beta blocker licensed for HF ie

Bisoprolol , carvedilol and nebivolol

Offer an MRA in addition to an ACE i or ARB and beta blocker if they continue to have symptoms of heart failure
 Measure Na and K and assess renal function before and after starting an MRA and after each dose increment and BP
 Once the target or max tolerated dose of MRA is reached monitor treatment monthly for 3 months and then atleast every 6 months and at any time the person becomes acutely unwell

If remains symptomatic refer specialist for consideration of

○ Sacubitril/ Valsartan ○ Ivabradine ○ Digoxin ○ Hydralazine + Nitrate ○ Device therapy ○ Transplant

References ; Further reading
 CKS NHS heart failure- Chronic Chronic heart failure in adults : diagnosis and management NICE guideline NG 106 September 2018 NICE Pathways Chronic heart failure Heart Failure : Epidemiology Pathophysiology and Diagnosis John McMurray et al Chronic heart failure in adults : summary of updated NICE guidance BMJ 2018 ; 362