NICE Publishes Updated Guidance on the Management of Acute Heart Failure

Dawn O'Shea

November 19, 2021

NICE has published updated guidance on the diagnosis and management of acute heart failure (AHF). The guideline includes recommendations on diagnosis, assessment and monitoring, initial pharmacological and non-pharmacological treatment, management after stabilisation, and the use of mechanical devices.

Diagnosis

The guidance states that all hospitals admitting people with suspected AHF should provide a specialist heart failure team based on a cardiology ward, and patients admitted to hospital with suspected AHF should have early and continuing input from a dedicated specialist heart failure team.

A follow‑up clinical assessment should be undertaken by a member of the specialist heart failure team within two weeks of discharge.

In people presenting with new suspected AHF, a single measurement of serum natriuretic peptides (BNP or NT‑proBNP) should be used. Thresholds to rule out heart failure are BNP <100 ng/L or NT‑proBNP <300 ng/L.

In people presenting with new suspected AHF with raised natriuretic peptide levels, a transthoracic Doppler 2D echocardiography should be performed (preferably within 48 hours) to establish the presence or absence of cardiac abnormalities.

Pulmonary artery catheterisation should not be routinely offered to AHF patients.

Initial pharmacological treatment

Patients should not routinely be offered opiates, nitrates, sodium nitroprusside, inotropes or vasopressors.

Intravenous (IV) nitrates can continue to be used in specific circumstances, such as for people with concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease, in a level 2 care setting.

Inotropes or vasopressors can be considered for AHF people with potentially reversible cardiogenic shock, but these should only be administered in a cardiac care unit or high dependency unit or an alternative level 2 setting.

Intravenous diuretic therapy is recommended, starting with either a bolus or infusion strategy. For admitted people already taking a diuretic, a higher dose of diuretic can be considered unless there are concerns with patient adherence to diuretic therapy before admission.

Initial non-pharmacological treatment

Continuous positive airways pressure (CPAP) or non‑invasive positive pressure ventilation (NIPPV) should be avoided in patients with AHF and cardiogenic pulmonary oedema. However, for patients who have cardiogenic pulmonary oedema with severe dyspnoea and acidaemia, consider starting non‑invasive ventilation without delay.

Invasive ventilation can be used in people with AHF and respiratory failure or reduced consciousness or physical exhaustion.

Ultrafiltration should not be routinely offered, but can be considered for people with confirmed diuretic resistance.

After stabilisation

After stabilisation, patients on beta-blockers should continue treatment, provided heart rate is >50 beats per minute and in the absence of second or third degree atrioventricular block, or shock.

For inpatients who no longer require IV diuretics, start or restart beta‑blocker treatment for AHF due to left ventricular systolic dysfunction, and ensure the patients condition is stable for 48 hours before discharging.

Offer an angiotensin‑converting enzyme inhibitor (or angiotensin receptor blocker if this cannot be tolerated) and an aldosterone antagonist to people with AHF and reduced left ventricular ejection fraction. If the angiotensin‑converting enzyme inhibitor (or angiotensin receptor blocker) is not tolerated, an aldosterone antagonist should still be offered.

This updated guidance on AHF sees the removal of guidance on valvular surgery and percutaneous intervention. Recommendations on these interventions are now available in NICE’s guideline on heart valve disease.

At an early stage, discussions should be held with a centre providing mechanical circulatory support in relation to patients with potentially reversible severe AHF or those who are potential candidates for transplantation.

Research

The guideline also calls for research on new approaches to the management of AHF.

It says randomised controlled trials are needed to investigate whether the addition of low‑dose dopamine or a thiazide diuretic to standard therapy leads to more clinically and cost effective decongestion in people admitted to hospital for treatment of decompensated heart failure. The study should aim to investigate the diuretic effect of dopamine as well as effects on renal function.

In addition, NICE is calling for a study comparing outcomes with intra‑aortic balloon counter‑pulsation pump and those seen with the use of inotropes/vasopressors in people with AHF and hypoperfusion syndrome.

A randomised trial is also required to determine whether ultrafiltration is more clinically and cost effective than conventional diuretic therapy for people admitted to hospital with decompensated heart failure.

Acute heart failure: diagnosis and management: Clinical guideline [CG187]. National Institute for Health and Care Excellence. 2021 November 17.

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