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This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the NICE guideline [NG106] on Chronic Heart Failure in adults, always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

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Primary Care guidelines podcast:

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The resources consulted can be found here:

Chronic Heart Failure in adults: diagnosis and management - NICE guideline [NG106]:

·      https://www.nice.org.uk/guidance/ng106

The visual summary for the diagnosis of chronic heart failure can be found here:

·      https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-diagnosis-visual-summary-pdf-6663137726

The visual summary for the management of chronic heart failure can be found here:

·      https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-management-visual-summary-pdf-6663137725

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Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to do a quick up-to-date review of the NICE guidelines on the diagnosis and management of chronic heart failure in adults, including the visual summary flowcharts, always focusing on what is relevant in Primary Care only.

Right, so let’s jump into it.

And we start with the diagnosis. We will take a detailed history and examination and, we will consider the following investigations to exclude other potential conditions:

·      an ECG

·      a chest X-ray

·      blood tests including FBC, renal, liver and thyroid function tests, a lipid profile and HbA1c

·      urinalysis and

·      peak flow or spirometry.

And, if we suspect heart failure, we will measure the N-terminal pro-B-type natriuretic peptide, which from now on we will refer to as NT‑proBNP

High levels of NT‑proBNP carry a poor prognosis. For this reason:

·      If the levels are very high, i.e. above 2,000 ng/litre or 236 pmol/litre, we will refer them urgently to have specialist assessment and a transthoracic echocardiogram within 2 weeks.

·      However, if the levels are only moderately high, that is, between 400 and 2,000 ng/litre or 47 to 236 pmol/litre, we will refer them also urgently but to be seen within 6 weeks.

We also need to be aware that:

·      an NT‑proBNP level less than 400 ng/litre or 47 pmol/litre in an untreated person makes heart failure less likely so we should consider alternative causes and refer if in doubt.

·      the NT‑proBNP level does not differentiate between heart failure with reduced ejection fraction and heart failure with preserved ejection fraction. Let’s remember that heart failure with preserved ejection fraction is usually associated with impaired left ventricular relaxation, rather than left ventricular contraction, so it has normal left ventricular ejection fraction and evidence of diastolic dysfunction, whereas the opposite is true for heart failure with reduced ejection fraction, when the ejection fraction is below 40%.

·      the NT‑proBNP level can be reduced in obesity, African or African–Caribbean family background, or drugs such as diuretics, ACE inhibitors, ARBs, beta‑blockers, and mineralocorticoid receptor antagonists or MRAs

·      conversely, the NT‑proBNP level can be high due to other reasons such as, for example, age over 70 years, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia, like in PE and COPD, eGFR less than 60, sepsis, diabetes, and liver cirrhosis.

The purpose of the initial transthoracic echocardiogram is to exclude valve disease, assess left ventricular function, and detect intracardiac shunts. However, alternative cardiac imaging can be considered if the transthoracic images are poor.

Finally, if a patient with a pre-existing diagnosis of heart failure has not been fully investigated in the past, then we should arrange the appropriate investigations in order to confirm the diagnosis.

NICE has produced a useful visual summary covering the diagnosis of chronic heart failure in the form of a flow chart. Let’s have a look at it.

If we suspect chronic heart failure

We will take a full history and examination

And then we will investigate by measuring the NT-proBNP level

And by performing alternative investigations such as an ECG, a CXR, blood tests, urinalysis and peak flow or spirometry.

If the NT-proBNP levels are very high, we will refer to specialist services urgently to be seen within 2 weeks.

If the NT-proBNP levels are only moderately high, we will refer to specialist services, also urgently but to be seen within 6 weeks

And this specialist assessment should also include a transthoracic echocardiogram.

If the NT-proBNP levels are not high

Then, we will consider alternative diagnoses and we will get specialist input if in doubt.

Finally, if heart failure is confirmed on an echocardiogram, then we will assess the severity and possible causes as well as correctable factors.

Let’s now have a look at the treatment.

I will start with the management that is applicable to all forms of heart failure, that is, both HFpEF and HFrEF,

but we need to be aware that there are specific recommendations for HFrEF that I will cover later.

So, for all types of heart failure, diuretics should be used for the relief of congestive symptoms and fluid retention, and titrated (up and down) according to need. A low to medium dose of loop diuretics (for example, no more than 80 mg furosemide per day) should be used in HFpEF.

As general recommendations, we will avoid verapamil, diltiazem and short-acting dihydropyridine agents like nifedipine in people who have heart failure with reduced ejection fraction.

Amiodarone should be initiated by a specialist only

And if a patient is in sinus rhythm, anticoagulation should be considered for those with a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus.

In terms of non-pharmacological treatment:

·      Flu and pneumococcal vaccinations are recommended

·      In women of childbearing potential, contraception and pregnancy should be discussed and the patient referred if pregnancy is being considered or it occurs.

·      We will not routinely advise sodium or fluid restriction but we will restrict fluids is there is dilutional hyponatraemia and we will advise reducing salt intake if it is excessive. We should also advise against salt substitutes that contain potassium.

·      Air travel will be possible for most patients.

·      And we should follow the DVLA guidelines in terms of driving.

So, let’s now have a look at the specific treatment for HFrEF, that is, when the left ventricular function is below 40%

As first-line treatment, we will offer an ACE inhibitor and a beta‑blocker licensed for heart failure using clinical judgement when deciding which drug to start first. If an ACE inhibitor is not tolerated, we will substitute it with an ARB licensed for heart failure.

Currently, the betablockers licensed for heart failure in the UK are:

·      Bisoprolol

·      Carvedilol

·      Nebivolol

And currently, the ARBs licensed for heart failure in the UK are:

·      Candesartan

·      Losartan

·      Valsartan

But we will not offer ACE inhibitors if there is a clinical suspicion of haemodynamically significant valve disease, until seen by a specialist.

In terms of betablockers, we will not withhold them solely because of age or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease or chronic obstructive pulmonary disease. Also, if a patient develops heart failure, we will switch people who are already taking a beta-blocker for something else, for example, angina or hypertension, to a beta-blocker licensed for heart failure.

After this, we will offer a mineralocorticoid receptor antagonist (or MRA) such as spironolactone, in addition to an ACE inhibitor (or ARB) and beta-blocker, if they continue to have symptoms.

When prescribing ACE inhibitors, ARBs, betablockers and MRAs:  

·      We will start at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose is reached.

·      We will measure sodium and potassium, and assess renal function, before and 1 to 2 weeks after starting an ACE inhibitor, ARB or MRA, and after each dose increment.

·      We will measure blood pressure before and after each dose increment and, in addition, we will assess the heart rate when giving betablockers.

·      Once the target or maximum tolerated dose is reached, we will monitor the treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell.

As well as ACE inhibitors, ARBs, betablockers and MRAs, there are a number of other drugs that can be given for heart failure by a heart failure specialist. These are:

·      Dapagliflozin and empagliflozin

·      Ivabradine

·      Sacubitril valsartan

·      Hydralazine in combination with nitrate and

·      Digoxin

We will give the same treatment to people who have heart failure with reduced ejection fraction and chronic kidney disease but:

·      If the eGFR is between 30 and 45, we will consider lower doses and/or slower titration of dose of ACE inhibitors, ARBs, MRAs and digoxin, monitoring closely and taking into account the increased risk of hyperkalaemia.

·      If the eGFR is below 30 we will liaise with a renal physician.

Monitoring treatment for all types of heart failure should include:

·      a clinical assessment

·      a review of medication

·      and an assessment of renal function. Monitoring potassium is particularly important if the patient is on digoxin or an MRA.

The frequency of monitoring depends on the clinical situation and stability of the person. The monitoring interval should be short (days to 2 weeks) if the clinical condition or medication has changed, but is needed at least 6-monthly for patients who are stable.

We will consider measuring NT-proBNP for monitoring purposes only in a specialist care setting.

A cardiac rehabilitation programme should be offered, unless their condition is unstable.

And in terms of palliative care, we will not offer long-term home oxygen therapy for heart failure alone.

And just like for the diagnosis, NICE has produced a useful visual summary covering the management of chronic heart failure in the form of a flow chart. Let’s have a look at it.

Once chronic heart failure has been diagnosed,

We can use diuretics for congestive symptoms and fluid retention, and then any further treatment will depend on the type of heart failure.

If it is heart failure with preserved ejection fraction, we will simply manage comorbidities such as hypertension, atrial fibrillation, ischaemic heart disease and diabetes

and we will offer a cardiac rehabilitation programme unless the condition is unstable.

On the other hand, if it is heart failure with reduced ejection fraction, we will offer and ACEI and a betablocker as first line, followed by an MRA if symptoms persist.

And we can give an ARB if the patient cannot tolerate an ACEI because of side effects.

And we will do this, as well as offering cardiac rehabilitation unless the condition is unstable.

If that is not enough, then we move to specialist referral for re-assessment and consideration of other forms of treatment.

So, if symptoms persist despite first-line treatment, specialist services may consider one or more of the following options:

Replacing the ACEI or ARB by sacubitril valsartan or

Adding ivabradine or

Adding hydralazine and a nitrate,

which can also be considered if ACEIs and ARBs are not tolerated at an earlier stage and

adding digoxin

and finally

Although it does not appear on this flowchart, SGLT2 inhibitors such as dapagliflozin and empagliflozin are now recommended for both HFpEF and HFrEF, so they could be another option here.

And that is it, a quick summary of the NICE guideline on chronic heart failure.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.