Heart failure- NICE guideline

Summary

In this informative video, Dr. Fernando Florido, a UK-based GP, provides a comprehensive overview of the NICE guidelines for managing chronic heart failure. He emphasizes the importance of a personalized care plan, discusses diagnostic criteria, and outlines treatment strategies, including the use of diuretics, ACE inhibitors, ARBs, beta blockers, and mineralocorticoid receptor antagonists. Special considerations for patients with reduced ejection fraction and those with comorbidities like CKD are also highlighted, along with the role of innovative therapies like sacubitril/valsartan in improving heart failure outcomes.

Takeaways

• 📝 The first recommendation by NICE is to write a care plan for every patient with heart failure, including diagnosis, medication, monitoring, functional abilities, social circumstances, and clinical management details.
• 🏥 Diagnosis of heart failure is initially based on history and clinical examination, with symptoms like shortness of breath, fatigue, swelling, rapid or irregular pulse, and cough or wheezing.
• 🌡️ Confirmation of heart failure diagnosis involves measuring NT-pro BNP levels and referring for a transthoracic echocardiography if levels are above certain thresholds, indicating poor prognosis.
• 🩺 Examination findings in left-sided heart failure include cool, clammy skin, cyanosis, and crackles in both lung fields, while right-sided heart failure signs include elevated jugular venous pressure and hepatomegaly.
• 💊 Treatment for heart failure involves diuretics for symptom relief and fluid retention, with specific dosage recommendations based on the type of heart failure (e.g., preserved ejection fraction).
• 💉 Anticoagulation should be considered for patients with a history of thrombolism, left ventricular aneurysm, or intracardiac thrombus.
• 💊 For heart failure with reduced ejection fraction, first-line treatment includes ACE inhibitors, beta blockers, and ARBs, with specific recommendations on drug choices and dosing.
• 🚫 Calcium channel blockers like Verapamil and short-acting hydropyridine agents are to be avoided in heart failure with reduced ejection fraction.
• 🌡️ Monitoring for all heart failure patients includes annual flu vaccination, pneumococcal vaccination, and advice on smoking, alcohol, and air travel, with specific considerations for driving restrictions.
• 🏥 Interventional procedures like coronary revascularization are not routinely offered, but cardiac transplantation, implantable cardioverter defibrillators, and cardioresynchronization therapy can be considered for appropriate patients.
• 💊 The combination of sacubitril/valsartan works by inhibiting neprilysin, which prevents the breakdown of natriuretic peptides, thus providing a prolonged beneficial effect in heart failure treatment.

Q & A

What is the first recommendation given by NICE for managing chronic heart failure?

The first recommendation by NICE is to write a care plan for every patient with heart failure. This care plan should include diagnosis and course of the disease, medication, monitoring functional abilities, social circumstances, details of clinical management, symptoms to look out for in case of deterioration, how to access the specialist team, and contact details for healthcare services for urgent care.

What are some typical symptoms of heart failure mentioned in the script?

Typical symptoms of heart failure may include shortness of breath on exertion and when lying down, fatigue and weakness, bilateral leg ankle or foot swelling, rapid or irregular pulse, reduced ability to exercise, persistent cough or wheezing, abdominal swelling, and rapid weight gain from fluid retention.

What diagnostic tests are recommended to confirm heart failure?

To confirm the diagnosis of heart failure, NICE recommends measuring the NT-pro BNP or BNP levels and referring for a transthoracic echocardiography within two weeks if the NT-pro BNP level is above 2000 nanograms per liter or 236 picamoles per liter.

What are the implications of a high NT-pro BNP level in the diagnosis of heart failure?

A high NT-pro BNP level, above 2000 nanograms per liter or 236 picamoles per liter, is associated with a poor prognosis and thus urgency is given to refer the patient for a transthoracic echocardiography within two weeks.

How does the treatment approach differ for heart failure with reduced ejection fraction versus heart failure with preserved ejection fraction?

In heart failure with preserved ejection fraction, diuretics are given for the relief of congestive symptoms and fluid retention, and typically no more than a low to medium dose of a loop diuretic is prescribed. Heart failure with reduced ejection fraction requires more specific treatments such as ACE inhibitors, ARBs, beta blockers, and mineralocorticoid receptor antagonists.

What are some factors that can affect NT-pro BNP levels?

Factors that can affect NT-pro BNP levels include obesity, African-Caribbean family background, treatments with heart failure drugs such as diuretics, ACE inhibitors, ARBs, beta blockers, or mineral corticoid receptor antagonists, age of 70 years, left ventricular hypertrophy, ischemia, tachycardia, right ventricular overload, hypoxemia, renal failure, sepsis, diabetes, or liver cirrhosis.

What is the purpose of transthoracic echocardiography in the management of heart failure?

The purpose of transthoracic echocardiography is to exclude valve disease, assess the systolic and diastolic ventricular function, and detect intracardiac shunts.

What are the treatment options for heart failure with reduced ejection fraction?

The first line treatment for heart failure with reduced ejection fraction includes ACE inhibitors and beta blockers licensed for heart failure. If there are side effects with ACE inhibitors, ARBs are used. If neither ACE inhibitors nor ARBs are tolerated, hydrolyzine in combination with nitrate is considered. Mineralocorticoid receptor antagonists are added if there are persistent symptoms.

What are the considerations for initiating certain drugs in the treatment of heart failure?

Drugs such as sacubitril/valsartan, hydralazine in combination with nitrates, and digoxin should be initiated by specialists alone. These treatments require careful monitoring and are typically used for moderate to severe symptoms of heart failure.

How does sacubitril/valsartan work in the treatment of heart failure?

Sacubitril/valsartan is a combination product where sacubitril acts as a neprilysin inhibitor, blocking the enzyme that breaks down natriuretic peptides, thus prolonging their beneficial effects. Valsartan is an ARB that blocks the effects of Angiotensin II, which accumulates due to neprilysin inhibition. This combination helps in managing the symptoms of heart failure.