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.
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.
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.