What the NICE chronic heart failure guideline means for frontline GPs

NICE's updated chronic heart failure guideline, published on Wednesday, spells out the latest advice for GPs on diagnosis and management in primary care. Dr Clare J Taylor, a GP, researcher and guideline committee member, highlights the key points for GPs.

Dr Clare J Taylor
Dr Clare J Taylor

Heart failure is a common and treatable condition. An average 10,000-patient practice will have 100-200 patients with heart failure - more if serving an older population - and diagnose 20-25 new cases per year. An updated NICE guideline on chronic heart failure was published on Wednesday. Below, I have summarised the most salient parts of the guideline relevant to practising GPs like you and me.

GPs play an important role in recognising the signs of heart failure and referring for diagnosis. All patients with symptoms (breathless, ankle swelling, tiredness) should have a N-terminal pro-B-type natriuretic peptide (NT-proBNP) test and if above 400pg/ml, be referred for echocardiography and specialist assessment - within six weeks.

If the NT-proBNP level is greater than 2,000pg/ml, assessment should be done within two weeks. The previous recommendation that patients with a history of myocardial infarction should be referred directly for echocardiography has been removed.

Clinical diagnosis

The clinical diagnosis of heart failure should be made by a lead physician with subspecialty training in heart failure - usually a cardiologist - and the new guideline recommends an extended first consultation with the specialist team to ensure the diagnosis is fully explained, including the type of heart failure as this influences management.

All patients with heart failure may benefit from diuretic therapy to reduce fluid overload. Fluid and salt restriction are no longer recommended unless intake is particularly high. Treatment of heart failure with preserved ejection fraction (HFpEF) is otherwise limited to modification of comorbidities such as diabetes and hypertension. All patients with heart failure should be offered a personalised exercise-based cardiac rehabilitation programme once their condition is stable.

The treatment of HFrEF remains angiotensin converting enzyme inhibitors (ACE-I), or angiotensin receptor blocker (ARB) if intolerant, and beta-blockers (BB) first line but with the addition of a mineralocorticoid receptor antagonist (MRA) such as spironolactone recommended if symptoms persist, so called ‘triple therapy’. Close monitoring of renal function, particularly potassium, is required in these patients.

Treatment options

Further second line options, such as the angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril-valsartan and ivabradine, remain with the specialist team. It is important to remember that ARNIs replace the ACE-I or ARB so the medication screen in the patient record may need to be updated.

The new guideline recognises the importance of the specialist heart failure multidisciplinary team (MDT) - a lead physician with training in heart failure, specialist nurse and healthcare professional with expertise in specialist prescribing - working in collaboration with the primary care team. The specialist MDT should confirm the diagnosis for all new patients, initiate and optimise treatment for patients with a new diagnosis or worsening symptoms and provide a written care plan.

Once stable, patients may be managed in primary care but any changes to medications or clinical status should be communicated to the specialist MDT with referral back if required. The guidance is available online, including one-page algorithms useful for diagnosis and management.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

Labour promises 5,000 GP training posts and premises boost in £26bn 'NHS rescue plan'

Labour promises 5,000 GP training posts and premises boost in £26bn 'NHS rescue plan'

The Labour party has promised a £26bn real-terms increase in NHS funding by 2023/24...

Can GPs believe the Conservatives' promise to deliver 6,000 more GPs?

Can GPs believe the Conservatives' promise to deliver 6,000 more GPs?

In the run-up to the 2015 general election, then health secretary Jeremy Hunt promised...

PCN recruitment scheme 'disadvantages innovative practices', LMCs warn

PCN recruitment scheme 'disadvantages innovative practices', LMCs warn

Innovative GP practices are 'disproportionately disadvantaged' by the funding scheme...

GPs demand power to close lists and drop home visits amid workload crisis

GPs demand power to close lists and drop home visits amid workload crisis

LMCs will set out major concerns over practice workload later this month, highlighting...

GP services disrupted as floods cause havoc

GP services disrupted as floods cause havoc

GPs have been left battling to get into work and deliver services, with some finding...

GMC warning for GPs working for online services

GMC warning for GPs working for online services

A set of principles aimed at helping GPs and other health professionals who practise...