Heart failure - chronic - NICE CKS PDF

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Summary

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Description

No outcome measures were found during the review of this topic. Back to top

Audit criteria No audit criteria were found during the review of this topic.

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QOF indicators

Table 1. Indicators related to heart failure in the Quality and Outcomes Framework (QOF) of the General Medical Services (GMS) contract.

Indicator

Points Payment stages

HF001 The contractor establishes and maintains a register of patients with heart failure.

4

HF002 The percentage of patients with a diagnosis of heart failure (diagnosed on or after 1 April 6 2006) which has been confirmed by an echocardiogram or by specialist assessment 3 months

50-90%

before or 12 months after entering on to the register. HF003 In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, the percentage of patients who are currently treated with an ACE-I or ARB

10

HF004 In those patients with a current diagnosis of heart failure due to left ventricular systolic 9 dysfunction who are currently treated with an ACE-I or ARB, the percentage of patients who are additionally currently treated with a beta-blocker licensed for heart failure

60-100%

40-65%

Data from: [BMA and NHS Employers, 2014 (/heart-failure-chronic#!references)]

QIPP - Options for local implementation

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Renin-angiotensin system drugs Review and, where appropriate, revise prescribing to ensure it is in line with NICE guidance. Dual therapy with an angiotensin-converting enzyme (ACE) inhibitor plus an angiotensin receptor blocker has only a limited place in treatment — for example, in a small minority of people with heart failure. [NICE, 2015 (/heart-failure-chronic#!references)]

NICE quality standards

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No NICE quality standards were found during the review of this topic.

What is it?

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Heart failure is a complex syndrome in which the ability of the heart to maintain the circulation of blood is impaired as a result of a structural or functional impairment of ventricular filling or ejection [NICE, 2018 (/heart-failurechronic#!references); Yancy et al, 2013 (/heart-failure-chronic#!references)]. Chronic heart failure can be classified

according to: The ejection fraction [European Society of Cardiology, 2012 (/heart-failure-chronic#!references); Yancy et al, 2013 (/heart-failure-chronic#!references)]. There is no agreement on what level should be used to separate normal from abnormal left ventricular ejection fraction (LVEF). The definition of reduced ejection fraction varies in clinical trials between a LVEF of less than or equal to 35 to 40% [Yancy et al, 2013 (/heart-failure-chronic#!references)]. Heart failure with reduced ejection fraction (HF-REF): Just over half of people with heart failure have evidence of reduced LVEF on echocardiography [NICE, 2018 (/heart-failure-chronic#!references)]. Heart failure with preserved ejection fraction (HF-PEF): Nearly half of people with heart failure have preserved LVEF on echocardiography [NICE, 2018 (/heart-failurechronic#!references)]. The time-course of heart failure [European Society of Cardiology, 2012 (/heart-failure-chronic#!references)]: Acute and chronic heart failure are terms used to define the rate of onset and duration of symptoms: Acute heart failure may be a new presentation of heart failure or may be a deterioration or 'decompensation' in a person with existing chronic heart failure. There is no agreed definition of the timescale of chronic heart failure although stable heart failure is a term used to describe a person with treated heart failure and symptoms which are unchanged for at least a month [European Society of Cardiology, 2012 (/heart-failure-chronic#!references)]. Symptomatic severity: The New York Heart Association (NYHA) has a functional classification of heart failure based on severity of symptoms and limitation of physical activity [American Heart Association, 1994 (/heart-failurechronic#!references); European Society of Cardiology, 2012 (/heart-failure-chronic#!references); Yancy et al, 2013 (/heart-failure-chronic#!references)]: Class I — no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, breathlessness, or palpitations. Class II — slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in undue breathlessness, fatigue, or palpitations. Class III — marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations. Class IV — unable to carry out any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken discomfort is increased. The terms 'right heart failure' and 'left heart failure' were previously used to reflect whether the predominant symptoms reflected congestion in the systemic (right) or pulmonary (left) veins. Congestive heart failure is a term which describes evidence of sodium and water retention. However these terms can be misleading and are not further used in this CKS topic.

What causes it?

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Many different conditions can lead to chronic heart failure with possible overlap between categories. Causes include: Myocardial disease Coronary artery disease (most common). Hypertension. Cardiomyopathies: Familial. Infective. Immune-mediated (for example autoimmune). Toxins (for example alcohol or cocaine).

Pregnancy. Infiltrative (for example sarcoidosis, amyloidosis, haemochromatosis, connective tissue disease). Valvular heart disease (for example aortic stenosis). Pericardial disease Constrictive pericarditis. Pericardial effusion. Congenital heart disease Arrhythmias (for example atrial fibrillation and other tachyarrythmias). High output states: Anaemia. Thyrotoxicosis. Phaeochromocytoma. Septicaemia. Liver failure. Arteriovenous shunts. Paget's disease. Thiamine (vitamin B1) deficiency. Volume overload End-stage chronic kidney disease. Nephrotic syndrome. Obesity Drugs including: Alcohol. Cocaine. Nonsteroidal anti-inflammatory drugs, beta-blockers, and calcium-channel blockers (may worsen pre-existing heart failure). [Feenstra et al, 1999 (/heart-failure-chronic#!references); Feenstra et al, 2002 (/heart-failure-chronic#!references); European Society of Cardiology, 2012 (/heart-failure-chronic#!references); McKelvie et al, 2013 (/heart-failurechronic#!references); Yancy et al, 2013 (/heart-failure-chronic#!references)]

How common is it?

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The prevalence of heart failure slowly increases with age until about 65 years of age, and then more rapidly. In the UK, the prevalence of heart failure is estimated to be about [NICE, 2018 (/heart-failure-chronic#!references)]: 1 in 35 people 65–74 years of age. 1 in 15 people 75–84 years of age. Just over 1 in 7 people 85 years of age or older. The average age at first diagnosis is 76 years of age [NICE, 2018 (/heart-failure-chronic#!references)]. People with heart failure with preserved ejection fraction (HF-PEF) are more likely to be older and female than those with heart failure with reduced ejection fraction (HF-REF) [European Society of Cardiology, 2012 (/heart-failurechronic#!references)]. Heart failure accounts for about [NICE, 2018 (/heart-failure-chronic#!references)]: 2% of all NHS hospitalized bed-days. 5% of all NHS medical emergency admissions. On average, a GP will look after 30 people with chronic heart failure and will suspect a new diagnosis in about 10 people annually [NICE, 2018 (/heart-failure-chronic#!references)]. Nearly half of people with heart failure have HF-PEF. The proportions reported in epidemiological studies vary from 40–70%, but values are difficult to interpret because the studies used various definitions of heart failure and different thresholds for classifying ejection fraction as reduced or normal [Sanderson, 2007 (/heart-failurechronic#!references); European Society of Cardiology, 2012 (/heart-failure-chronic#!references)].

What is the prognosis?

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Mortality About 50% of people with heart failure die within 5 years of diagnosis [Yancy et al, 2013 (/heart-failurechronic#!references)]. A UK population-based study found that the 6-month mortality rate for people with heart failure was 14% [Mehta et al, 2009 (/heart-failure-chronic#!references)]. A National UK Heart Failure audit found that hospital inpatient mortality was 11% in 2009 [The NHS Information Centre, 2009 (/heart-failure-chronic#!references)]. About 40% of people admitted to hospital with heart failure die or are re-admitted within 1 year [European Society of Cardiology, 2008 (/heart-failure-chronic#!references)]. Prognostic indicators [European Society of Cardiology, 2012 (/heart-failure-chronic#!references); Pocock et al, 2013 (/heart-failure-chronic#!references)] Prognosis can be difficult to estimate for a person because heart failure often has an unpredictable trajectory, with stable periods interrupted by episodic acute destabilization. Poor prognostic indicators include: Increased age. Reduced ejection fraction (the lower the ejection fraction, the poorer the prognosis). The presence of comorbidities (such as atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease, depression, and diabetes mellitus). Worsening severity of symptoms (based on the New York Heart Association classification). The presence of signs such as raised jugular venous pressure, third heart sound, low systolic blood pressure, and tachycardia. Obesity or cachexia. Smoking. Heart failure caused by ischaemic heart disease, and specifically a history of myocardial infarction. The presence of complex ventricular arrhythmias (frequent premature ventricular complexes and non-sustained ventricular tachycardia).

What are the complications?

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Cardiac arrhythmias Atrial fibrillation is the most common arrhythmia in people with heart failure [European Society of Cardiology, 2012 (/heart-failure-chronic#!references)]. The prevalence increases with the severity of heart failure, increasing from about 10% in people with mild to moderate heart failure (New York Heart Association [NYHA] classes II and III) to 50% in people with severe heart failure (NYHA class IV) [Maisel and Stevenson, 2003 (/heart-failurechronic#!references)]. For more information, see the CKS topic on Atrial fibrillation (/atrial-fibrillation). Ventricular arrhythmias are common in people with heart failure, particularly people with a dilated left ventricle and reduced ejection fraction [European Society of Cardiology, 2012 (/heart-failure-chronic#!references)]. Depression Major depressive disorder is present in up to 20% of people with heart failure [Thombs et al, 2008 (/heart-failurechronic#!references)]. Cachexia (wasting) This is defined as the loss of 6% or more of total body weight within the previous 6–12 months. Wasting occurs in lean tissue (muscle mass), and fat [European Society of Cardiology, 2012 (/heart-failure-chronic#!references)]. Cachexia may occur in 10–15% of people with heart failure, especially those with a reduced ejection fraction. It is associated with more severe symptoms, reduced functional capacity, more frequent hospitalization, and decreased survival rates [European Society of Cardiology, 2012 (/heart-failure-chronic#!references)]. Chronic kidney disease (CKD)

CKD is common in people with heart failure and is strongly associated with increased morbidity and mortality [European Society of Cardiology, 2012 (/heart-failure-chronic#!references)]. For more information, see the CKS topic on Chronic kidney disease (/chronic-kidney-disease). Sexual dysfunction Sexual dysfunction is common in people with heart failure. This may be related to cardiovascular disease, fatigue, weakness, the use of drugs (such as beta-blockers), or depression and anxiety [European Society of Cardiology, 2008 (/heart-failure-chronic#!references)]. For more information, see the CKS topic on Erectile dysfunction (/erectile-dysfunction). Sudden cardiac death About half of the deaths in people with heart failure are related to sudden cardiac death [European Society of Cardiology, 2008 (/heart-failure-chronic#!references)].

When should I suspect chronic heart failure?

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Chronic heart failure can be difficult to diagnose because the symptoms and signs are often non-specific. Ask about typical symptoms of heart failure: Breathlessness — on exertion, at rest, on lying flat (orthopnoea), nocturnal cough, or waking from sleep (paroxysmal nocturnal dyspnoea). Fluid retention (ankle swelling, bloated feeling, abdominal swelling, or weight gain). Fatigue, decreased exercise tolerance, or increased recovery time after exercise. Light headedness or history of syncope. Ask about risk factors: Coronary artery disease including previous history of myocardial infarction, hypertension, atrial fibrillation, and diabetes mellitus. Drugs, including alcohol. Family history of heart failure or sudden cardiac death under the age of 40 years. Examine for: Tachycardia (heart rate over 100 beats per minute) and pulse rhythm. A laterally displaced apex beat, heart murmurs, and third or fourth heart sounds (gallop rhythm). Hypertension. For more information, see the CKS topic on Hypertension - not diabetic (/hypertension-notdiabetic). Raised jugular venous pressure. Enlarged liver (due to engorgement). Respiratory signs such as tachypnoea, basal crepitations, and pleural effusions. Dependent oedema (legs, sacrum), ascites. Obesity. For more information, see the CKS topic on Obesity (/obesity).

Basis for recommendation

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These recommendations are based on expert opinion in guidelines from the National Institute for Health and Clinical Excellence (NICE) guideline Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care [NICE, 2018 (/heart-failure-chronic#!references)], the European Society of Cardiology Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 [European Society of Cardiology, 2012 (/heart-failure-chronic#!references)], and the American College of Cardiology Foundation/American Heart Association Task Force Guideline for the management of heart failure [Yancy et al, 2013 (/heart-failurechronic#!references)]. The recommendation to ask about family history of sudden cardiac death is based on expert opinion in a narrative review article 10 steps before you refer for palpitations [Wolff and Cowen, 2009 (/heart-failurechronic#!references)] which states that deaths under the age of 40 years are significant as the likelihood of an

inherited cardiac condition is much greater in this age group than in older people.

How should I manage a person with suspected heart

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failure? Review the person's medication and if appropriate reduce or stop any drugs that may cause or worsen heart failure. If symptoms are sufficiently severe, start a loop diuretic such as: Furosemide 20–40 mg daily. Bumetanide 0.5–1.0 mg daily. Torasemide 5–10 mg daily. If higher doses are required to relieve the person's symptoms, check adherence to treatment, check for alternative causes (/heart-failure-chronic#!diagnosisSub:3), and seek specialist advice or consider admission (based on clinical judgement). Seek specialist advice for pregnant women before initiating any drug treatments.

Basis for recommendation

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These recommendations are based on guidelines from the Scottish Intercollegiate Guidelines Network (SIGN) Management of chronic heart failure [SIGN, 2016 (/heart-failure-chronic#!references)], the National Institute for Health and Clinical Excellence (NICE) Chronic heart failure national guidelines for diagnosis and management in primary and secondary care [NICE, 2018 (/heart-failure-chronic#!references)], on a previous and current guideline published by the European Society of Cardiology [European Society of Cardiology, 2008 (/heart-failure-chronic#!references); European Society of Cardiology, 2012 (/heart-failure-chronic#!references)], and the expert opinion of previous reviewers of this CKS topic. Reviewing medication This recommendation is based on expert opinion in a narrative review [Williams and Oakeshott, 2014a (/heartfailure-chronic#!references)]. Starting loop diuretics The recommendation to start a loop diuretic to relieve symptoms is extrapolated from the guidelines from SIGN [SIGN, 2016 (/heart-failure-chronic#!references)], NICE [NICE, 2018 (/heart-failure-chronic#!references)], and the European Society of Cardiology [European Society of Cardiology, 2012 (/heart-failure-chronic#!references)], and is recommended in a review article [Williams and Oakeshott, 2014a (/heart-failure-chronic#!references)]. CKS recommends that specialist advice should be sought if daily doses higher than furosemide 40 mg (or equivalent) are needed because: There may be a need to consider an alternative diagnosis (particularly if the person is responding poorly to a diuretic). High doses of loop diuretic may cause profound hypotension if an angiotensin-converting enzyme (ACE) inhibitor needs to be started, as symptomatic first-dose hypotension is more likely to occur in people taking diuretics, particularly if the dose of diuretic is high [European Society of Cardiology, 2012 (/heart-failurechronic#!references); BNF 72, 2016 (/heart-failure-chronic#!references)]. High doses of diuretic may result in hypokalaemia and other electrolyte disturbances, and acute kidney injury and chronic kidney disease have been reported [European Society of Cardiology, 2012 (/heart-failurechronic#!references)]. The expert opinion of previous reviewers of this CKS topic agreed that the daily dose of a loop diuretic should not exceed furosemide 40 mg (or equivalent) for the management of suspected heart failure, unless specialist

advice is obtained. Checking adherence to treatment, alternative causes, and seeking specialist advice or considering admission This recommendation is pragmatic and based on what CKS considers to be good clinical practice. Seeking specialist advice for pregnant women This recommendation is based on expert opinion that a high index of suspicion is needed to avoid late diagnosis of peripartum cardiomyopathy in the guidelines from the European Society of Cardiology Guidelines on the management of cardiovascular diseases during pregnancy [European Society of Cardiology, 2011 (/heart-failurechronic#!references)], and information that a risk assessment should be carried out early in pregnancy by a specialist obstetrician, cardiologist, and anaesthetist in the guideline from the Royal College of Obstetricians and Gynaecologists Cardiac disease and pregnancy [RCOG, 2011 (/heart-failure-chronic#!references)]. Additionally, some medications used for treatment of heart failure (such as ACE-inhibitors and angiotensin-II receptor antagonists) are contraindicated in pregnancy [European Society of Cardiology, 2012 (/heart-failurechronic#!references)].

How should I assess a person with suspected chronic heart

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failure? If chronic heart failure is suspected (/heart-failure-chronic#!diagnosisSub): Arrange admission if the person has severe symptoms. If there is uncertainty about the need for admission, seek specialist advice. For pregnant women (or women who have given birth within 6 months) with suspected heart failure, either arrange emergency admission (based on clinical judgement) or seek immediate specialist advice. Measure their N-terminal pro-B-type natriuretic peptide level (NT-proBNP) If the NT-pro-BNP level is above 2000 pg/mL (236 pmol/L), refer urgently for specialist assessment and echocardiography to be seen within 2 weeks. If the NT-pro-BNP level is between 400–2000 (tel:400–2000) pg/mL (47–236 pm...