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Chronic heart failure in adults: management

Diagnosing heart failure

diagnosing heart failure

Serum natriuretic peptides
High levels—BNP>400 pg/ml (116 pmol/litre) or NTproBNP>2000 pg/ml (236 pmol/litre) Raised levels—BNP 100–400 pg/ml (29–116 pmol/litre) or NTproBNP 400–2000 pg/ml (47–236 pmol/litre) Normal levels—BNP<100 pg>

Treating heart failure

Treating heart failure

ACE=angiotensin-converting enzyme; ARB=angiotensin II receptor blockers; ICD=implantable cardioverter defibrillator; CRT=cardiac resynchronization therapy.
* For more information on drug treatment see appendix D of the NICE guideline and 'Chronic kidney disease' (NICE clinical guideline 73).
Consider an ICD in line with 'Implantable cardiovascular defibrillators for arrhythmias' (NICE technology appraisal guidance 95).
NYHA class III–IV.
§ Not all ARBs are licensed for use in heart failure in combination with ACE inhibitors. |NYHA class II–III.
This does not include mixed race. For more information see the full guideline at www.nice.org.uk/guidance/CG108.
** Consider CRT in line with 'Cardiac resynchronisation therapy for the treatment of heart failure' (NICE technology appraisal guidance 120).

Lifestyle advice for patients with heart failure

  • Exercise
    • see ‘Rehabilitation’ below
  • Smoking
    • strongly advise patients not to smoke
    • consider referral to smoking cessation services
  • Alcohol
    • advise patients with alcohol-related heart failure to abstain
    • discuss consumption with other patients and tailor advice to clinical circumstances
  • Sexual activity
    • be prepared to broach sensitive issues such as sexual activity
  • Vaccination
    • offer:
      • an annual vaccination against influenza
      • a one-off vaccination against
        pneumococcal disease
  • Air travel
    • consider clinical circumstances when advising about air travel
  • Driving regulations
    • check the latest Driver and Vehicle Licensing Agency guidelines for drivers of large goods and passenger carrying vehicles (see www.dft.gov.uk/dvla for regular updates)

Monitoring

Clinical review

  • Monitor all patients. Include:
    • clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status
    • a review of drug treatment, including need for changes and possible side effects
    • a minimum of serum urea, electrolytes, creatinine and eGFR*
  • When a patient is admitted to hospital because of heart failure, seek advice on their management plan from a specialist in heart failure

Rehabilitation

  • Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure
    • ensure the patient is stable and does not have a condition (such as uncontrolled ventricular response to atrial fibrillation, or uncontrolled hypertension) or device (for example, a high-energy pacing device set to be activated at rates achieved during exercise) that would preclude the programme
    • include a psychological and educational component in the programme
    • the programme may be incorporated within an existing cardiac rehabilitation programme

Discharge planning and long-term care

Discharge planning

  • Discharge patients from hospital only when their condition is stable and their management plan optimised. When considering the timing of discharge take account of:
    • patient and carer wishes
    • level of care and support available in the community

* This is a minimum. Patients with comorbidities or co-prescribed medications will require further monitoring. Monitoring serum potassium is particularly important if a patient is taking digoxin or an aldosterone antagonist

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG108

National Institute for Health and Care Excellence. Chronic heart failure in adults: management. August 2010
First included: October 2003.