My name is Fernando Florido and I am a GP in the United Kingdom. In this episode I go through the NICE guidelines “Chronic heart failure in adults: diagnosis and management” or NG106, Published on 12 September 2018
There is a YouTube version of this and other episodes that you can access here:
· https://www.youtube.com/@nicegp
The NICE guideline on chronic heart failure can be found here:
· Website: https://www.nice.org.uk/guidance/ng106/chapter/Recommendations or as PDF: https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-in-adults-diagnosis-and-management-pdf-66141541311685
· Or download here: https://1drv.ms/b/s!AiVFJ_Uoigq0lgl6iwROprZsSZ2u?e=G7Lte2
The NICE recommendations on dapaglifozin and empaglifozin in HF can be found:
· On website here:
o Dapaglifozin in HF: https://www.nice.org.uk/guidance/ta679 or https://www.nice.org.uk/guidance/ta679/resources/dapagliflozin-for-treating-chronic-heart-failure-with-reduced-ejection-fraction-pdf-82609327985605
o Empaglifozin in HF: https://www.nice.org.uk/guidance/ta773 or https://www.nice.org.uk/guidance/ta773/resources/empagliflozin-for-treating-chronic-heart-failure-with-reduced-ejection-fraction-pdf-82611494690245
· Or downloaded here:
o Dapaglifozin: https://1drv.ms/b/s!AiVFJ_Uoigq0lgfx8IoyYutMx9rh?e=1Fc3uc
o Empaglifozin: https://1drv.ms/b/s!AiVFJ_Uoigq0lggUBPl4p_XX1XzF?e=aMVtBp
The Visual summaries on diagnosis and management of heart failure can be found here:
1-Diagnosis: https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-diagnosis-visual-summary-pdf-6663137726
2-Management: https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-management-visual-summary-pdf-6663137725
· Or download here:
1-Diagnosis: https://1drv.ms/b/s!AiVFJ_Uoigq0lgW9dPRAHiaT3Ueg?e=hfuU3x
2-Management:
https://1drv.ms/b/s!AiVFJ_Uoigq0lgZLGWycIkNN-Mcu?e=bTlnAN
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Transcript
Hello everyone and welcome.
Today we are going to look at the NICE guidelines on Chronic heart failure.
My name is Fernando Florido and I am a GP in the United Kingdom. Remember that there is also a YouTube version of these episodes so have a look in the podcast description. Let’s jump straight into it.
The first recommendation given by NICE is probably something that is often neglected. And this is to write a care plan for every patient with HF. This care plan must include:
· diagnosis and cause
· medication and monitoring
· functional abilities and any social circumstances
· details of clinical management including
o how to access the specialist team
o contact details for a named healthcare coordinator or alternative specialist care providers, for urgent care or review.
When it comes to making the Diagnosis we will base it initially on the history, and clinical examination.
Some of the typical symptoms of HF may include:
· Shortness of breath on exertion or 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
· Very rapid weight gain from fluid retention
Examples of examination findings in
left-sided heart failure include cool clammy skin, cyanosis, a laterally displaced point of maximum impulse consistent with an enlarged ventricle and on auscultation we can find lung crackles and a gallop rhythm. Signs in right sided heart failure include an elevated JVP, ankle of leg edema, ascites, hepatomegaly, a parasternal heave and hepatojugular reflux. Signs of both left and right sided heart failure can be present.
In order to confirm the diagnosis
We will measure the N-terminal pro-B-type natriuretic peptide (NT‑proBNP), which I will refer to now as simply BNP.
And we will refer for a transthoracic echocardiography:
· within 2 weeks if the NT-proBNP level is above 2,000 ng/litre (236 pmol / litre) and the urgency is because very high NT-PproNP levels carry a poor prognosis or refer
· within 6 weeks if the NT-proBNP level is between 400 and 2,000 ng/litre (47 to 236 pmol/litre)
· a NT-PROBNP level of less than 400 ng/litre (47 pmol/litre) in an untreated person makes a diagnosis of heart failure less likely. In these cases, we will look for alternative causes.
But remember:
· the NT-PROBNP level does not differentiate between heart failure with reduced ejection fraction and heart failure with preserved ejection fraction.
· The NT-PROBNP level can be reduced by obesity, African or African–Caribbean family background, or treatment with HF drugs such as diuretics, ACE inhibitors, ARBs, beta‑blockers, or mineralocorticoid receptor antagonists (MRAs)
· The NT-PROBNP level can be increased due to causes other than heart failure (for example, age over 70 years, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including PE and COPD], eGFR less than 60, sepsis, diabetes, or liver cirrhosis).
The purpose of transthoracic echocardiography is to exclude valve disease, assess the systolic and diastolic ventricular function, and detect intracardiac shunts. Heart failure caused by valve disease will need specialist referral.
We will arrange alternative imaging (for example, radionuclide angiography, cardiac MRI or transoesophageal echocardiography) if the transthoracic echocardiography gives a poor image.
We will also arrange other tests including:
· ECG
· chest X-ray
· blood tests including full blood count, renal, liver and thyroid function as well as a lipid profile and HbA1c
· urinalysis
· peak flow or spirometry.
In order to give the necessary information to the patient, NICE recommends an extended first consultation, followed by a second consultation 2 weeks later.
When it comes to treatment, there are specific recommendations for HFrEF but first we will look at the advice for all types of heart failure
Firstly, we will give Diuretics for the relief of congestive symptoms and fluid retention and titrate them up and down according to need. In particular, in heart failure with preserved ejection fraction we will normally give no more than a low to medium dose of loop diuretics (for example, less than 80 mg furosemide per day) and refer if this is not enouogh.
By the way, I just wish to clarify that heart failure with preserved ejection fraction is usually associated with impaired left ventricular relaxation, rather than left ventricular contraction, and is characterised by normal left ventricular ejection fraction with evidence of diastolic dysfunction.
Amiodarone initiation will be by a specialist and we will review the need to continue at every 6‑monthly clinical review. Amiodarone monitoring must include 6 monthly liver and thyroid function tests.
In sinus rhythm, anticoagulation should be considered for those with a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus.
We will now focus on the treatment of heart failure with reduced ejection fraction. By the way, I just want to clarify that Heart failure with reduced ejection fraction is when the ejection fraction is below 40%.
By way of introduction, we will say that some SGLT2 inhibotors such as dapaglifozin and empaglifozin have been shown to help in HFrEF even in the non-diabetic population. The guidance on their use in HF is covered outside this guideline, but in summary, NICE says that both Dapagliflozin and empaglifozin are recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction in adults, only if it is used as an add- on to optimised standard care with ACE inhibitors or ARBs, and beta blockers, mineralocorticoid receptor antagonists (MRAs) or sacubitril valsartan. I will put the link to the full SGLT2 guidance in the video description.
See NICE's technology appraisal guidance on dapagliflozin and empagliflozin for treating chronic heart failure with reduced ejection fraction
In terms of Calcium-channel blockers, we will avoid verapamil, diltiazem and short-acting dihydropyridine agents (like standard release nifedipine) in heart failure with reduced ejection fraction.
The First-line treatment in heart failure with reduced ejection fraction is as follows:
1. An ACE inhibitor and a beta‑blocker licensed for heart failure. The beta-blockers licensed in the UK for the treatment of heart failure are bisoprolol, carvedilol, and nebivolol. And we will use our clinical judgement when deciding which drug to start first. But we will not give an ACE inhibitor if there is haemodynamically significant valve disease until the valve disease has been assessed by a specialist.
a. We will give an ARB licensed for heart failure if there are side effects with ACE inhibitors. ARB licensed for heart failure in the UK are Candesartan, losartan, and valsartan.
b. If neither ACE inhibitors nor ARBs are tolerated, we will seek specialist advice, in order to consider hydralazine in combination with nitrate.
c. We will not withhold beta-blockers only because of age or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease or chronic obstructive pulmonary disease.
d. And, if stable, we will switch people already taking a beta-blocker for a comorbidity (for example, angina or hypertension), to a beta-blocker licensed for heart failure. That is again bisoprolol, carvedilol, and nebivolol in the UK.
2. If there are persistent symptoms, we will then give an mineralocorticoid receptor antagonists (MRA), such as spironolactone or eplerenone, in addition to an ACE inhibitor (or ARB) and beta-blocker.
Now, for all these drugs, that is ACEI, ARB, betablocker and MRA:
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 BP and renal function, including sodium and potassium levels, before and 1 to 2 weeks after starting the drug, and after each dose increment. We will also assess heart rate if giving betablockers.
Once the target or maximum tolerated dose is reached, we will monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell.
NICE recommends that the following drugs should be initiated by a Specialist
· Ivabradine
· Sacubitril valsartan
· Hydralazine in combination with nitrate
· Digoxin
Ivabradine is recommended if:
· NYHA class II to IV stable chronic heart failure with systolic dysfunction and
· sinus rhythm with a heart rate of 75 beats per minute (bpm) or more and
· in combination with standard therapy including beta-blocker therapy, ACE inhibitors and aldosterone antagonists, or when beta‑blocker therapy is contraindicated or not tolerated and
· with a left ventricular ejection fraction of 35% or less.
Sacubitril valsartan is recommended if:
· NYHA class II to IV symptoms and
· with a left ventricular ejection fraction of 35% or less and
· already taking a stable dose of ACE inhibitors or ARBs.
By the way, if you want to learn a bit more about Sacubitril valsartan, stick around until the end, when I will give you a bit more information about it.
Hydralazine in combination with nitrate, is recommended especially if:
· the person is of African or Caribbean family origin and
· has moderate to severe heart failure NYHA class III/IV with reduced ejection fraction.
Digoxin is recommended for worsening or severe symptoms despite first-line treatment. Routine monitoring of serum digoxin concentrations is not recommended. A digoxin concentration measured within 8 to 12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non‑adherence.
There are special considerations when treating heart failure with reduced ejection fraction in people with chronic kidney disease or CKD
If the eGFR is between 30 and 45 we will offer the same treatment but using lower doses and/or slower titration of ACEI, ARBs, MRAs and digoxin.
If the eGFR is below 30 we will involve the renal team.
And we will monitor closely the medication of CKD patients because of the increased risk of hyperkalaemia.
Other general recommendations in terms of management are:
1. an annual flu vaccination and a once only pneumococcal vaccination
2. Contraception and pregnancy for women of childbearing potential
3. Give appropriate advice on Smoking and alcohol
4. Air travel will be possible for most, depending on their clinical condition.
5. In terms of driving, there may be restrictions for Large Goods and Passenger Carrying Vehicles and, in the UK, we will check the DVLA website for regular updates.
6. We will not routinely restrict sodium or fluid consumption. Instead, we will ask about salt and fluid consumption and:
o advise fluid restriction if there is dilutional hyponatraemia
o advise reducing intake if there are high levels of salt and/or fluid consumption.
o We will however advise to avoid salt substitutes that contain potassium.
In terms of further monitoring for all types of heart failure
Apart from what has already been discussed, we will carry out full clinical assessment at every review.
If a person is taking digoxin or an MRA we will monitor potassium levels closely.
And we will consider monitoring NT-PROBNP levels only if:
· under 75
· there is heart failure with reduced ejection fraction and
· the eGFR is above 60 .
In terms of Interventional procedures
1. Coronary revascularisation should not be routinely offered but
2. Cardiac transplantation, Implantable cardioverter defibrillators and cardiac resynchronisation therapy can be offered to the right patients.
Cardiac rehabilitation should normally be offered unless the HF is unstable.
And finally, in Palliative care
We will not offer long-term home oxygen therapy, although it may still be offered for comorbidities, such as for some people with COPD.
Now, this is the end of the actual NICE guideline on chronic heart failure. But if you are interested in learning how Sacubitril/valsartan works, here is some background information.
The first thing to understand is that the pathophysiology of heart failure involves an abnormal activation of the renin-angiotensin-aldosterone system (RAAS). This leads to vasoconstriction, hypertension, increased aldosterone levels, increased sympathetic tone, and eventually, cardiac remodelling, all of which worsen the disease over time. ACEIs or ARBs play a major role in reducing HF morbidity and mortality by blocking this abnormal activation
At the same time that the renin-angiotensin-aldosterone system is activated, the natriuretic peptide system is also activated, hence the elevated BNP and NT-pro BNP seen in heart failure. This compensatory mechanism leads to vasodilation, natriuresis, and diuresis. As a result, the natriuretic peptide system decreases blood pressure, lowers the sympathetic tone, and reduces aldosterone levels. The natriuretic peptide system functions antagonistically to the renin-angiotensin-aldosterone system and has favourable impact on heart failure. Natriuretic peptides are broken down by an enzyme called neprilysin.
Sacubitril/valsartan is a combination product. Sacubitril is a pro-drug that, upon activation, acts as a neprilysin inhibitor. So it works by blocking the action of neprilysin, thus preventing the breakdown of natriuretic peptides, which leads to a prolonged duration of the favourable effects of these peptides.
However, because neprilysin also breaks down angiotensin II, inhibiting neprilysin will accumulate angiotensin II. For this reason, a neprilysin inhibitor cannot be used alone; it must always be combined with an ARB to block the effect of the excess angiotensin II. This is why Valsartan is used.
Another important substance broken down by neprilysin is bradykinin; neprilysin inhibition will also cause a build-up of bradykinin. Therefore, sacubitril cannot be used with an ACEI due to an increased risk of angioedema if both these drugs are combines or given in a short timeframe. And this is why when switching between ACEI and sacubitril/valsartan, the patient must undergo a 36-hour washout period to lower the risk of angioedema.
We have come to the end of this video. I hope that you have found it useful and, if so, please hit the like and subscribe buttons. Thank you for watching and good-bye
