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National Collaborating Centre for Chronic Conditions (UK). Chronic Heart Failure: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care. London: Royal College of Physicians (UK); 2003. (NICE Clinical Guidelines, No. 5.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

1Introduction

1.1. Definition of heart failure

Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation. The syndrome of heart failure is characterised by symptoms such as breathlessness and fatigue, and signs such as fluid retention.

There is no single diagnostic test for heart failure, and diagnosis relies on clinical judgement based on a combination of history, physical examination and appropriate investigations. These are discussed in more detail in the diagnosis section (Section 6).

1.2. Clinical context

Around 900,000 people in the UK today have heart failure – with almost as many with damaged hearts but, as yet, no symptoms of heart failure.1 Both the incidence and prevalence of heart failure increase steeply with age, with the average age at first diagnosis being 76 years.2 While around 1 in 35 people aged 65–74 years has heart failure, this increases to about 1 in 15 of those aged 75–84 years, and to just over 1 in 7 in those aged 85 years and above.3 The risk of heart failure is higher in men than in women in all age groups, but there are more women than men with heart failure due to population demographics’.1

The most common cause of heart failure in the UK is coronary artery disease – with many patients having suffered a myocardial infarction in the past.1 A history of hypertension is also common, as is atrial fibrillation. Heart damage of unknown cause – such as dilated cardiomyopathy – accounts for just under 15% of cases under the age of 75.4 There are few reliable data for different ethnic groups; it is likely that people of African or Afro-Caribbean origin are more likely to develop heart failure due to hypertension rather than coronary artery disease, whereas those of Asian origin have a greater risk of developing heart failure due to coronary artery disease – often accompanied by obesity and diabetes mellitus.

Heart failure has a poor prognosis: just under 40% of patients diagnosed with heart failure die within a year – but thereafter the mortality is less than 10% per year.5 Survival rates are similar to those from cancer of the colon, and worse than those from cancer of the breast or prostate.6 Younger patients do better, as do patients with no other medical problems.

On average, a general practitioner will look after 30 patients with heart failure, and suspect a new diagnosis of heart failure in perhaps 10 patients annually. Those who work in more deprived areas are likely to have more cases. The cost of general practitioner consultations has been estimated at £45 million per year, with an additional £35 million for GP referrals to outpatient clinics. In addition, community-based drug therapy costs the NHS around £129 million per year.7

Heart failure accounts for a total of 1 million inpatient bed days − 2% of all NHS inpatient bed-days – and 5% of all emergency medical admissions to hospital. Hospital admissions due to heart failure are projected to rise by 50% over the next 25 years – largely due to the ageing of the population. It is estimated that the total annual cost of heart failure to the NHS is around £716 million, or around 1.8% of the total NHS budget: approximately 70% of this total is due to the costs of hospitalisation.1,7 The costs increase with disease severity, with the healthcare costs for patients with the most severe symptoms between 8 and 30 times greater than those with mild symptoms.8

As well as NHS costs, heart failure also places a burden on other agencies such as social services and the benefits system, and of course on the patients with heart failure and their families and caregivers.

For patients and their carers, the costs are more difficult to quantify but the burden is both financial and via adverse effects on their quality of life. The financial costs of heart failure to the patient and family arise from prescription charges (in patients under the age of 60), attendance at GP surgeries and outpatient clinics, hospital stays, modifications to the home and loss of earnings due to absence from work or loss of employment (although given that heart failure is more common in older people, productivity losses may not be as great as for other chronic conditions).

Quality of life is affected by the physical limitations imposed by the disease, and also by the social limitations that follow from this and the emotional problems that may also arise. These symptoms can be caused by the disease itself, by co-morbidities, or can result from the side effects of treatment. There is, however, evidence that both pharmacological and non-pharmacological treatments can improve patient quality of life, both in terms of physical functioning and well-being.9

1.3. Guideline aims

This guideline offers best practice advice on the care of adult patients (aged 18 years or older) who have symptoms or a diagnosis of chronic heart failure. It aims to define the most effective combination of symptoms, signs and investigations required to establish a diagnosis of heart failure, and those which will influence therapy or provide important prognostic information. It also gives guidance on the treatment, monitoring and support of patients with heart failure.

1.4. For whom is the guideline intended?

Clinical guidelines have been defined as ‘systematically developed statements to assist both practitioner and patient decisions in specific circumstances’.10

These guidelines are aimed at helping all healthcare professionals provide optimal services for patients with heart failure by:

  • providing individual clinicians with a set of explicit statements on the best way to manage the most common clinical problems, and to maximise the effectiveness of the service
  • providing commissioning organisations and provider services with specific guidance on the best way to provide complex services, to maximise efficiency and equity.

Others, including the general public, may find the guideline of use in understanding the clinical approach to heart failure. Separate short form documents for the public and clinical staff are available which summarise the recommendations without full details of the supporting evidence. These documents are available from the NICE website (www.nice.org.uk) or, within the UK, from the NHS Response Line (0541 555 455).

1.5. Underlying guideline principles

The main principles behind the development of this guideline were that it should:

  • consider all issues that are important in the management of patients with chronic heart failure
  • use published evidence wherever this is available
  • be useful and usable to all professionals
  • take full account of the perspective of the person with heart failure and their carers
  • indicate areas of uncertainty or controversy needing further research.

1.6. Definition of a specialist

The term ‘specialist’ is applicable to a wide range of healthcare professionals; however within the context of this guideline, the term specialist is most often used in relation to the prescription of drugs or the decision to perform invasive investigations or procedures.

As such, a specialist is defined as a healthcare professional with special knowledge and experience in heart failure. As well as cardiologists, this could include a wide range of physicians and (increasingly) other professional groups in primary and secondary care.

1.7. Structure of document

Sections 613 of the document contain the guidelines, each of which covers a set of related topics. For each topic the layout is similar.

The background to the topic is provided in one or two paragraphs that simply set the recommendations in context.

Then the evidence statements are given which summarise the evidence detailed in the evidence tables (Appendix J or www.rcplondon.ac.uk/pubs/books/chf/). In addition, there is an evidence statement about the health economic evidence where this is available. These evidence statements and tables aim to provide context and aid the reader’s understanding of why each recommendation was made.

The main recommendations follow. These are graded to indicate the strength of the evidence behind the recommendation (see Section 3). In some sections of the guideline, additional text providing more detailed guidance follows a recommendation.

1.8. Guideline limitations

The document and recommendations are subject to various limitations. The sponsoring authority, NICE, is concerned primarily with health services, and so these recommendations only indirectly refer to social services, the voluntary sector and post-transplant care. Nonetheless, the importance of other agencies cannot be over-stated and in each locality the aim should be to integrate heart failure care across all relevant sectors.

A systematic approach was used to locate and appraise the evidence and explicit inclusion criteria were applied. Due to the magnitude of the literature potentially relevant to heart failure, the inclusion criteria aimed to limit the included studies to those of a higher quality conducted primarily in patients with heart failure. Where these were not available, well-conducted studies outside heart failure, or lower level studies in patients with heart failure, were included.

1.9. Scope

The guideline was developed in accordance with a predetermined scope, which detailed the remit of the guideline development and specified those aspects of heart failure to be included and excluded.

Before the guideline development began, this scope was subjected to stakeholder consultation in accordance with processes established by NICE.11

The scope is detailed below.

Inclusions

The guideline covers the care provided by primary and secondary healthcare professionals who have direct contact with, and make decisions concerning the care of, patients with heart failure. The guideline also addresses the interface between primary and secondary care, including in what circumstances patients should be referred to or admitted to secondary care.

Where available, evidence for the following circumstances was considered:

  • referral for invasive procedures including pacing, implantable cardiac defibrillators, coronary artery bypass grafting, angioplasty, valve surgery and transplantation surgery
  • referral to supportive and palliative care.

The guideline addresses all the key areas of managing chronic heart failure.

Diagnosis – Systolic and diastolic dysfunction, valve disease and the other causes of heart failure. The value of a range of diagnostic techniques including ECG, chest X-ray, biochemical markers and imaging techniques.

Treatments – The goals of treatment are defined in terms of symptom reduction, functional ability, hospitalisation and mortality.

Pharmacological treatments – The initiation, dosage, sequence and monitoring of the following preparations:

  • ACE inhibitors
  • angiotensin-II receptor antagonists
  • beta-blockers
  • digoxin
  • diuretics
  • nitrates and other vasodilators
  • spironolactone.

The guideline usually recommends within the licence indications. Exceptionally, where there was clear supporting evidence, recommendations outside the licence indications have been included. Where this is the case, it is clearly indicated to alert the reader.

Non-pharmacological treatment – Exercise programmes and rehabilitation. Lifestyle advice on diet, physical activity, weight reduction and smoking cessation.

Management of depression and/or anxiety – Only as it pertains directly to patients with heart failure.

Exclusions

This guideline does not include specific reference to ‘acute’ heart failure, but does include comment on exacerbation of the syndrome and the causes and treatment of this, recognising that chronic heart failure often has an undulating course.

The guideline does not address the screening or diagnosis of people who are asymptomatic, nor does it address the management of patients with right heart failure as a consequence of respiratory disease.

In addition, the guideline does not cover the organisational aspects of heart failure management. It does not therefore address models of care, the roles or composition of primary or secondary healthcare teams and competencies, skillmix or training requirements.

This guideline is relevant to the work of, but does not cover the practice of, social services, the voluntary sector and those working in post-transplant care.

Presentation

This heart failure guideline is available in three forms:

  • this full guideline, which contains the complete evidence statements and recommendations (with evidence tables accessible in web-based format)
  • a short form version
  • a version of the short form prepared specifically for the public, including patients and their carers.

1.10. Plans for guideline revision

The process of reviewing the evidence is expected to begin four years after the date of issue of this guideline (July 2007). Reviewing may begin earlier than four years if significant evidence that affects the guideline recommendations is identified sooner. The updated guideline will be available within two years of the start of the review process.

Copyright © 2003, Royal College of Physicians of London.
Cover of Chronic Heart Failure
Chronic Heart Failure: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care.
NICE Clinical Guidelines, No. 5.
National Collaborating Centre for Chronic Conditions (UK).

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NICE (National Institute for Health and Care Excellence)

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