Management of Chronic Heart Failure in
Adults: Synopsis of the National Institute for
Health and Clinical Excellence Guideline
JONATHAN MANT, MD; ABDALLAH AL-MOHAMMAD, MD;
SHARON SWAIN, BA, PHD; AND PHILIPPE
LARAMEE,DC,MSC, FOR THE GUIDELINE DEVELOPMENT
GROUP
CHRIS FONTIMAYOR MS-III
MERCER UNIVERSITY
SCHOOL OF MEDICINE
DR. RAHIMI
9/9/2011
Heart Failure (HF)
 A common clinical syndrome representing the end-
stage of a number of different cardiac diseases
 Result of any structural or functional cardiac
disorder that impairs the ability of the ventricle to fill
with or eject blood
 Two types
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Systolic Dysfunction
Diastolic Dysfunction
Heart Failure
 Symptoms – dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nocturnal cough, confusion and
memory loss in advanced stages, diaphoresis and
cool extremities at rest
 New York Heart Association (NYHA) Classification
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Class I – symptoms only with vigorous activities
Class II – symptoms with moderate exertion
Class III – symptoms with normal daily activities
Class IV – symptoms at rest
National Institute for Health and Clinical
Excellence (NICE)
 Develops clinical practice guidelines for the National
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Health Service of England and Wales
First guideline on HF in 2003
Target population: Non-pregnant adults with symptoms
of chronic HF
Exclusion: Patients with acute HF or acute exacerbations
of chronic HF
Updated every 3 years
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Literature searches for new evidence, warnings from licensing
agencies , and major changes in costs
Actively seek out the views of health care professionals and patients
Guideline Development Process
 Guideline development group (GDG)– general practitioners,
specialist nurses, a consultant physician, consultant
cardiologists, and 2 members representing patients and
caregivers
 Clinical question
Literature review
Evidence grading
High Quality Evidence for Pharmacologic
Therapy
 ACE inhibitors and ß-blockers reduce morbidity and
increase survival in patients with left ventricular systolic
dysfunction
 No difference exists between selective ß-blockers (ie
metoprolol) and nonselective ß-blockers (ie carvedilol) on
the combined end point of mortality and hospitalization
 Combination therapy of ARBs and ACE inhibitors increases
risk of hyperkalemia
 Adding ARB to ACE inhibitor and ß-blocker reduces the
mortality and hospitalization caused by HF
Invasive Therapy Recommendations
 Patients who are at any stage of HF with left
ventricular systolic dysfunction should be considered
for an implantable cardioverter-defibrillator (ICD)
 Criteria
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Sustained ventricular tachycardia or non-sustained ventricular
tachycardia that is inducible on electrophysiology testing if the
left ventricular ejection fraction (LVEF) is less than 35%
QRS of duration of 120 ms or longer if the LVEF is less than
30%
Rehabilitation
 Moderate quality evidence shows that exercise rehab
reduces hospital admissions for HF and increases
long-term quality of life
 GDG recommends supervised group exercise
programs with psychological and educational
components
Monitoring Patients With HF
 Moderate quality evidence
 Therapy guided by serum natriuretic peptide levels results in a
reduction of hospitalizations due to HF
 Therapy guided by serum natriuretic peptide levels reduces
mortality in persons younger than 75
 Cost effective analysis demonstrated that serial
serum natriuretic peptide monitoring was cost
effective when used by specialists
 Significant heterogeneity of evidence for the use of
telemonitoring in decreasing hospitalizations
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GDG has no recommendation for telemonitoring
New Evidence Since the Implementation of the
2010 NICE guideline
 EMPHASIS-HF Study (Epleronone in Mild Patients
Hospitalization and Survival Study in Heart Failure)
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Significant reductions in hospitalization and mortality when
epleronone therapy is started in patients hospitalized during
the preceding 6 months or with persistent moderate elevation
of serum natriuretic peptide levels (BNP≥250 ng/L)
 SHIƒT (Systolic Heart Failure Treatment with the Iƒ
Inhibitor Ivabradine Trial)
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Ivabradine, Iƒ channel blocker in SA node, significantly
reduces unplanned hospitalization and mortality in patients
with HF due to left ventricular systolic dysfunction whose HR
remains higher than 70bpm
Discussion
 NICE guidelines are broadly consistent with other
international guidelines (ESC and AHA)
 Benefits
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Earlier diagnosis
Better management
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Decreased morbidity and mortality
Cost-effective
Level of Evidence