Diagnosis and management of Chronic Heart Failure in 2018: What does NICE say? PCCS Meeting Issues and Answers Conference Nottingham

Diagnosis and management of Chronic Heart Failure in 2018: What does NICE say? PCCS Meeting Issues and Answers Conference Nottingham

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE Chronic heart failure in adults: Diagnosis and management (NG106) September 2018

The Model of Care should ensure people receive the right care, at the right time, by the right team and in the right place

Compared with certain cancers, heart failure is associated with the second poorest survival rate The picture can't be displayed. In an observational study of 16,224 men and 14,842 women hospitalised with heart failure or different types of cancer: Median survival time of patients with heart failure was 16 months Only 25% of men and women survived 5 years Survival 1.0 0.8 0.6 0.4 0.2 Women 1.0 0.8 Breast 0.6 MI Bowel 0.4 Ovarian Heart failure 0.2 Lung Men MI Bladder Bowel Prostate Heart failure Lung 0.0 0 6 12 18 24 30 36 42 48 54 60 Months of follow-up 0.0 0 6 12 18 24 30 36 42 48 54 60 Months of follow-up MI, myocardial infarction. Stewart S et al. Eur J Heart Fail 2001;3:315 322.

Classifying heart failure (NICE CHF Guideline NG106) u Heart failure with reduced ejection fraction Heart failure with an ejection fraction below 40%. u Heart failure with preserved ejection fraction This is usually associated with impaired left ventricular relaxation, rather than left ventricular contraction and is characterised by normal or preserved left ventricular ejection fraction.

Diagnosing Heart Failure NICE CHF Guidelines NG106

Diagnostic Algorithm Take a detailed history and perform a clinical examination Perform ECG. Consider chest x-ray, blood tests, urinalysis, peak flow or spirometry Measure NT probnp NT pro BNP >2000ng/l (>236pmol/l) Refer urgently to be seen within 2 weeks NT pro BNP 400-2000ng/l (47-236pmol/l) Refer urgently to be seen within 6 weeks NT pro BNP <400ng/l (<47pmol/l) Specialist clinical assessment including echocardiography Exclude important valve disease, assess the systolic and diastolic function of the left ventricle, and detect intracardiacshunts Heart failure confirmed Heart failure not confirmed HF less likely Consider alternative causes for symptoms Assess HF severity Assess HF aetiology Identify precipitating factors and correctable causes HF unlikely If still concerned that symptoms might be related to heart failure, discuss with a specialist HFREF HFPEF Other abnormality

Diagnostic Algorithm Take a detailed history and perform a clinical examination Perform ECG. Consider chest x-ray, blood tests, urinalysis, peak flow or spirometry Measure NT probnp NT pro BNP >2000ng/l (>236pmol/l) NT pro BNP 400-2000ng/l (47-236pmol/l) NT pro BNP <400ng/l (<47pmol/l) Refer urgently to be seen within 2 weeks Refer urgently to be seen within 6 weeks Specialist clinical assessment including echocardiography Exclude important valve disease, assess the systolic and diastolic function of the left ventricle, and detect intracardiacshunts HF less likely Consider alternative causes for symptoms If still concerned that symptoms might be related to heart failure, discuss with a specialist

Natriuretic peptides in Heart Failure ANP atria :BNP ventricles Increase in response to volume expansion and pressure overload in failing heart Promotes natriuresis dilates the afferent and constricts the efferent arteriole in the kidney resulting in decreased Na reabsorption and inhibits the secretion of renin and aldosterone Vasodilatation (arteries and veins)

other factors which may alter NT-proBNP levels May Reduce Serum NT-proBNP Obesity Diuretics ACE/ARB ARA s Beta blockers May Increase Serum NT-proBNP LVH Ischaemia Tachycardia/AF RV overload Hypoxaemia COPD Sepsis Diabetes Renal impairment Hepatic cirrhosis Over 70 s

Diagnostic Algorithm Take a detailed history and perform a clinical examination Perform ECG. Consider chest x-ray, blood tests, urinalysis, peak flow or spirometry Measure NT probnp NT pro BNP >2000ng/l (>236pmol/l) NT pro BNP 400-2000ng/l (47-236pmol/l) NT pro BNP <400ng/l (<47pmol/l) Refer urgently to be seen within 2 weeks Refer urgently to be seen within 6 weeks Specialist clinical assessment including echocardiography Exclude important valve disease, assess the systolic and diastolic function of the left ventricle, and detect intracardiacshunts HF less likely Consider alternative causes for symptoms If still concerned that symptoms might be related to heart failure, discuss with a specialist

Team working in the management of heart failure NICE CHF Guideline NG106 The core specialist heart failure multidisciplinary team (MDT) should work in collaboration with the primary care team, and should include: ua lead physician with subspecialty training in heart failure (usually a consultant cardiologist) who is responsible for making the clinical diagnosis u a specialist heart failure nurse ua healthcare professional with expertise in specialist prescribing for heart failure. [2018]

Role of the Specialist Heart Failure MDT (NICE CHF Guideline NG106) The specialist heart failure MDT should: u diagnose heart failure u give information to people newly diagnosed with heart failure u manage newly diagnosed, recently decompensated or advanced heart failure (NYHA [New York Heart Association] class III to IV) u optimise treatment u start new medicines that need specialist supervision u continue to manage heart failure after an interventional procedure such as implantation of a cardioverter defibrillator or cardiac resynchronisation device u manage heart failure that is not responding to treatment. [2018]

Diagnostic Algorithm Take a detailed history and perform a clinical examination Perform ECG. Consider chest x-ray, blood tests, urinalysis, peak flow or spirometry Measure NT probnp NT pro BNP >2000ng/l (>236pmol/l) NT pro BNP 400-2000ng/l (47-236pmol/l) NT pro BNP <400ng/l (<47pmol/l) Refer urgently to be seen within 2 weeks Refer urgently to be seen within 6 weeks Specialist clinical assessment including echocardiography Exclude important valve disease, assess the systolic and diastolic function of the left ventricle, and detect intracardiacshunts HF less likely Consider alternative causes for symptoms If still concerned that symptoms might be related to heart failure, discuss with a specialist

Specialist clinical assessment including echocardiography Exclude important valve disease, assess the systolic and diastolic function of the left ventricle, and detect intracardiac shunts Heart failure confirmed Heart failure not confirmed Assess HF severity Assess HF aetiology Identify precipitating factors and correctable causes HF unlikely HFREF HFPEF Other abnormality

NICE Chronic Heart Failure First consultations for people newly diagnosed with heart failure The specialist heart failure MDT should offer people newly diagnosed with heart failure an extended first consultation, followed by a second consultation to take place within 2 weeks if possible. At each consultation: u discuss the person's diagnosis and prognosis u explain heart failure terminology u discuss treatments u address the risk of sudden death, including any misconceptions about that risk u encourage the person and their family or carers to ask any questions they have. [2018]

Communication The specialist heart failure MDT should write a summary for each person with heart failure that includes: u diagnosis and aetiology u medicines prescribed, monitoring of medicines, when medicines should be reviewed and any support the person needs to take the medicines u functional abilities and any social care needs social circumstances, including carers' needs. [2018] u Summary should be the basis of a care plan and shared with the patient/carer/ appropriate health professionals

Managing Heart Failure NICE CHF Guideline NG106

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Preserved Ejection Fraction (HFPEF) Manage co-morbid conditions such as high blood pressure, atrial fibrillation, ischaemic heart disease, and diabetes mellitus in line with NICE guidance Heart Failure with Reduced Ejection Fraction (HFREF) First line: Offer ACEI and BB Offer an MRA if symptoms continue All heart failure: Offer personalised, exercise-based cardiac rehabilitation programme, unless condition is unstable Specialist re-assessment Cardiac re-synchronisation therapy (CRT-P/D) in accordance with TA314 ICD in accordance with TA314 Replace ACEI (or ARB) by Sacubitril-Valsartan (if LVEF<35%) in accordance with TA388 If symptoms persist despite optimal first line therapy, seek specialist advice and consider one or more of the following options Add Ivabradine if in sinus rhythm with a HR of >75bpm and LVEF <35% in accordance with TA267 Add Hydralazine & nitrate (especially if of African/Caribbean descent) *Please refer to CG180 for recommendations on the use ofdigoxin in patients with atrial fibrillation Digoxin for worsening HF* Consider ARB if intolerant of ACEI Consider hydralazine & nitrate if intolerant of ACEI & ARB If the person s egfr is 30-45 ml/min/1.73 m2, consider lower doses and/or slower titration of dose of ACE Inhibitors, ARBs, mineralocorticoid receptor antagonists,sacubitril-valsartan and digoxin. Ifthe person s egfr is <30 ml/min/1.73 m2, liaise with the renal physician.

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Reduced Ejection Fraction (HFREF) First line: Offer ACEI and BB Offer an MRA if symptoms continue Consider ARB if intolerant of ACEI Specialist re-assessment Cardiac re-synchronisation therapy (CRT-P/D) in accordance with TA314 ICD in accordance with TA314 Replace ACEI (or ARB) by Sacubitril-Valsartan (if LVEF<35%) in accordance with TA388 If symptoms persist despite optimal first line therapy, seek specialist advice and consider one or more of the following options Add Ivabradine if in sinus rhythm with a HR of >75bpm and LVEF <35% in accordance with TA267 Add Hydralazine & nitrate (especially if of African/Caribbean descent) Consider hydralazine & nitrate if intolerant of ACEI & ARB Digoxin for worsening HF* *Please refer to CG180 for recommendations on the use ofdigoxin in patients with atrial fibrillation If the person s egfr is 30-45 ml/min/1.73 m2, consider lower doses and/or slower titration of dose of ACE Inhibitors, ARBs, mineralocorticoid receptor antagonists,sacubitril-valsartan and digoxin. Ifthe person s egfr is <30 ml/min/1.73 m2, liaise with the renal physician.

Monitoring medication (NICE CHF Guideline NG106) Beta blockers vintroduce beta-blockers in a start low, go slow manner. Assess heart rate and clinical status after each titration. Measure blood pressure before and after each dose increment of a beta-blocker. [2010, amended 2018]

NICE CHF Guideline NG106 Mineralocorticoid receptor antagonists (MRAs) Offer a mineralocorticoid receptor antagonist (MRA), in addition to an ACE inhibitor (or ARB) and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure. [2018]

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Reduced Ejection Fraction (HFREF) First line: Offer ACEI and BB Offer an MRA if symptoms continue Consider ARB if intolerant of ACEI Specialist re-assessment Cardiac re-synchronisation therapy (CRT-P/D) in accordance with TA314 ICD in accordance with TA314 Replace ACEI (or ARB) by Sacubitril-Valsartan (if LVEF<35%) in accordance with TA388 If symptoms persist despite optimal first line therapy, seek specialist advice and consider one or more of the following options Add Ivabradine if in sinus rhythm with a HR of >75bpm and LVEF <35% in accordance with TA267 Add Hydralazine & nitrate (especially if of African/Caribbean descent) Consider hydralazine & nitrate if intolerant of ACEI & ARB Digoxin for worsening HF* *Please refer to CG180 for recommendations on the use ofdigoxin in patients with atrial fibrillation If the person s egfr is 30-45 ml/min/1.73 m2, consider lower doses and/or slower titration of dose of ACE Inhibitors, ARBs, mineralocorticoid receptor antagonists,sacubitril-valsartan and digoxin. Ifthe person s egfr is <30 ml/min/1.73 m2, liaise with the renal physician.

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Reduced Ejection Fraction (HFREF) MDT OPTIMISATION First line: Offer ACEI and BB Offer an MRA if symptoms continue Consider ARB if intolerant of ACEI Specialist re-assessment Cardiac re-synchronisation therapy (CRT-P/D) in accordance with TA314 ICD in accordance with TA314 Replace ACEI (or ARB) by Sacubitril-Valsartan (if LVEF<35%) in accordance with TA388 If symptoms persist despite optimal first line therapy, seek specialist advice and consider one or more of the following options Add Ivabradine if in sinus rhythm with a HR of >75bpm and LVEF <35% in accordance with TA267 Add Hydralazine & nitrate (especially if of African/Caribbean descent) Consider hydralazine & nitrate if intolerant of ACEI & ARB Digoxin for worsening HF* *Please refer to CG180 for recommendations on the use ofdigoxin in patients with atrial fibrillation If the person s egfr is 30-45 ml/min/1.73 m2, consider lower doses and/or slower titration of dose of ACE Inhibitors, ARBs, mineralocorticoid receptor antagonists,sacubitril-valsartan and digoxin. Ifthe person s egfr is <30 ml/min/1.73 m2, liaise with the renal physician.

RAAS Medication ACE or ARB and MRA Monitoring medication (NICE CHF Guideline NG106) v Once the target or maximum tolerated dose is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell.

National Heart Failure Audit 15/16 Pharmacotherapy

Patients journey of care following incident heart failure: diagnostic tests, treatments and care pathways in 93,000 patients N. Conrad EHJ 2018 u 93,000 Primary care patients CPRD 2002-2014 u Primary care follow up decreased from 63% to 44% u Patients on ACE/ARB+ BB within 3 months of diagnosis increased from 18% to 63%.but in 2014 only 49% achieved target dose of ACE?ARB and 29% for BB and showed no signs of dose increment over the 12 months following there diagnosis of heart failure.

so what happens to your optimised patient now?

Managing heart failure Excellent Supportive care Functional status 2 3 Heart failure care 4 1 Death Time Sudden death event Transplant or ventricular assist device HF, heart failure; NYHA, New York Heart Association. Figure adapted from Goodlin SJ. J Am Coll Cardiol 2009;54:386 396. 5

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Reduced Ejection Fraction (HFREF) Specialist re-assessment Cardiac re-synchronisation therapy (CRT-P/D) in accordance with TA314 ICD in accordance with TA314 Replace ACEI (or ARB) by Sacubitril-Valsartan (if LVEF<35%) in accordance with TA388 First line: Offer ACEI and BB Offer an MRA if symptoms continue Discharged back to Primary care If symptoms persist despite optimal first line therapy, seek specialist advice and consider one or more of the following options Add Ivabradine if in sinus rhythm with a HR of >75bpm and LVEF <35% in accordance with TA267 Add Hydralazine & nitrate (especially if of African/Caribbean descent) Consider ARB if intolerant of ACEI Consider hydralazine & nitrate if intolerant of ACEI & ARB Digoxin for worsening HF* *Please refer to CG180 for recommendations on the use ofdigoxin in patients with atrial fibrillation If the person s egfr is 30-45 ml/min/1.73 m2, consider lower doses and/or slower titration of dose of ACE Inhibitors, ARBs, mineralocorticoid receptor antagonists,sacubitril-valsartan and digoxin. Ifthe person s egfr is <30 ml/min/1.73 m2, liaise with the renal physician.

Key recommendations for Primary care NICE CHF Guideline NG106

The role of primary care (NICE CHF Guideline NG106 ) The primary care team working within the specialist heart failure MDT should take over routine management of heart failure as soon as it has been stabilised and its management optimised. [2018]

The role of primary care (NICE CHF Guideline NG106 ) The primary care team should carry out the following for people with heart failure at all times, including periods when the person is also receiving specialist heart failure care from the MDT: u ensure effective communication links between different care settings and clinical services involved in the person's care u lead a full review of the person's heart failure care, which may form part of a long-term conditions review u recall the person at least every 6 months and update the clinical record u ensure that changes to the clinical record are understood and agreed by the person with heart failure and shared with the specialist heart failure MDT u arrange access to specialist heart failure services if needed. [2018]

Clinical review (NICE CHF Guideline NG106) All people with chronic heart failure need monitoring. This monitoring should include: u a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status u a review of medication, including need for changes and possible side effects u an assessment of renal function [2010, amended 2018] u The frequency of monitoring should depend on the clinical status and stability of the person. The monitoring interval should be short (days to 2 weeks) if the clinical condition or medication has changed, but is needed at least 6-monthly for stable people with proven heart failure. [2003]

Reviewing Heart Failure Patients in Primary Care u Stoke Road Practice,Bishops Cleeve,Cheltenham u Total Population 10.500 u Number of patients with a diagnosis of heart failure 112 u Number of HF patients not seen routinely in a Chronic Disease Clinic 14

Long Term Condition templates

Long Term Condition templates - Heart Failure

why is it important that HF is monitored at a LTC u Raises the profile of heart failure amongst all clinical staff - increased awareness of symptoms - earlier diagnosis - monitoring should lead to earlier re-referral - reduced hospital admissions - improved communication MDT-patient-Primary care - improved overall care and better supported patients - reduced costs

Managing heart failure Excellent Supportive care Functional status 2 3 Heart failure care 4 1 Death Time Sudden death event Transplant or ventricular assist device HF, heart failure; NYHA, New York Heart Association. Figure adapted from Goodlin SJ. J Am Coll Cardiol 2009;54:386 396. 5

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Reduced Ejection Fraction (HFREF) First line: Offer ACEI and BB Offer an MRA if symptoms continue Consider ARB if intolerant of ACEI Specialist re-assessment Cardiac re-synchronisation therapy (CRT-P/D) in accordance with TA314 ICD in accordance with TA314 Replace ACEI (or ARB) by Sacubitril-Valsartan (if LVEF<35%) in accordance with TA388 If symptoms persist despite optimal first line therapy, seek specialist advice and consider one or more of the following options Add Ivabradine if in sinus rhythm with a HR of >75bpm and LVEF <35% in accordance with TA267 Add Hydralazine & nitrate (especially if of African/Caribbean descent) Consider hydralazine & nitrate if intolerant of ACEI & ARB Digoxin for worsening HF* *Please refer to CG180 for recommendations on the use ofdigoxin in patients with atrial fibrillation If the person s egfr is 30-45 ml/min/1.73 m2, consider lower doses and/or slower titration of dose of ACE Inhibitors, ARBs, mineralocorticoid receptor antagonists,sacubitril-valsartan and digoxin. Ifthe person s egfr is <30 ml/min/1.73 m2, liaise with the renal physician.

Role of the Specialist Heart Failure MDT (NICE CHF Guideline NG106) The specialist heart failure MDT should: u diagnose heart failure u give information to people newly diagnosed with heart failure u manage newly diagnosed, recently decompensated or advanced heart failure (NYHA [New York Heart Association] class III to IV) u optimise treatment u start new medicines that need specialist supervision u continue to manage heart failure after an interventional procedure such as implantation of a cardioverter defibrillator or cardiac resynchronisation device u manage heart failure that is not responding to treatment. [2018]

Sacubitril/Valsartan

What is the NICE recommendation for Entresto? 1 NICE Technology Appraisal Guidance (TA388): 1 Entresto is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people: 1 With NYHA class II to IV symptoms and With a left ventricular ejection fraction of 35% or less, and Who are already taking a stable dose of ACE inhibitors or ARBs ACE, angiotensin converting enzyme; ARB, angiotensin II receptor blocker; NICE, National Institute for Health and Care Excellence; NYHA, New York Heart Association 1. NICE. Technology Appraisal Guidance (TA388). Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction. April 2016. https://www.nice.org.uk/guidance/ta388/. Last accessed October 2018

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Reduced Ejection Fraction (HFREF) First line: Offer ACEI and BB Offer an MRA if symptoms continue Consider ARB if intolerant of ACEI Specialist re-assessment Cardiac re-synchronisation therapy (CRT-P/D) in accordance with TA314 ICD in accordance with TA314 Replace ACEI (or ARB) by Sacubitril-Valsartan (if LVEF<35%) in accordance with TA388 If symptoms persist despite optimal first line therapy, seek specialist advice and consider one or more of the following options Add Ivabradine if in sinus rhythm with a HR of >75bpm and LVEF <35% in accordance with TA267 Add Hydralazine & nitrate (especially if of African/Caribbean descent) Consider hydralazine & nitrate if intolerant of ACEI & ARB Digoxin for worsening HF* *Please refer to CG180 for recommendations on the use ofdigoxin in patients with atrial fibrillation If the person s egfr is 30-45 ml/min/1.73 m2, consider lower doses and/or slower titration of dose of ACE Inhibitors, ARBs, mineralocorticoid receptor antagonists,sacubitril-valsartan and digoxin. Ifthe person s egfr is <30 ml/min/1.73 m2, liaise with the renal physician.

Ivabradine in Heart Failure

NICE TA 267 Ivabradine for treating Chronic Heart Failure Ivabradine is recommended as an option for treating chronic heart failure for people: u with New York Heart Association (NYHA) class II to IV stable chronic heart failure with systolic dysfunction and u who are in sinus rhythm with a heart rate of 75 beats per minute (bpm) or more and u who are given ivabradine in combination with standard therapy including beta-blocker therapy, angiotensin-converting enzyme (ACE) inhibitors and aldosterone antagonists, or when betablocker therapy is contraindicated or not tolerated and u with a left ventricular ejection fraction of 35% or less.

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Reduced Ejection Fraction (HFREF) First line: Offer ACEI and BB Offer an MRA if symptoms continue Consider ARB if intolerant of ACEI Specialist re-assessment Cardiac re-synchronisation therapy (CRT-P/D) in accordance with TA314 ICD in accordance with TA314 Replace ACEI (or ARB) by Sacubitril-Valsartan (if LVEF<35%) in accordance with TA388 If symptoms persist despite optimal first line therapy, seek specialist advice and consider one or more of the following options Add Ivabradine if in sinus rhythm with a HR of >75bpm and LVEF <35% in accordance with TA267 Add Hydralazine & nitrate (especially if of African/Caribbean descent) Consider hydralazine & nitrate if intolerant of ACEI & ARB Digoxin for worsening HF* *Please refer to CG180 for recommendations on the use ofdigoxin in patients with atrial fibrillation If the person s egfr is 30-45 ml/min/1.73 m2, consider lower doses and/or slower titration of dose of ACE Inhibitors, ARBs, mineralocorticoid receptor antagonists,sacubitril-valsartan and digoxin. Ifthe person s egfr is <30 ml/min/1.73 m2, liaise with the renal physician.

A-HeFT trial 2004 u 1050 self identified black patients u NYHA 3-4 + advanced HF u ISDN ( target 120mg daily )/Hydrallazine (target 225mg daily) in addition to standard therapy u Stopped early u Primary outcome all cause mortality +HF hospitalization + QOL u 43% RR reduction in all cause mortality ;33%RR reduction in first hospitalisation u Subsequent echo analysis showed significant effect on LV remodeling

Digoxin v Given for symptomatic benefit v No prognostic benefit v AF with LVSD (use in conjunction with beta blockers for rate control) v Indicated in SR if still symptomatic v Positive inotrope

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Reduced Ejection Fraction (HFREF) First line: Offer ACEI and BB Offer an MRA if symptoms continue Consider ARB if intolerant of ACEI Specialist re-assessment Cardiac re-synchronisation therapy (CRT-P/D) in accordance with TA314 ICD in accordance with TA314 Replace ACEI (or ARB) by Sacubitril-Valsartan (if LVEF<35%) in accordance with TA388 If symptoms persist despite optimal first line therapy, seek specialist advice and consider one or more of the following options Add Ivabradine if in sinus rhythm with a HR of >75bpm and LVEF <35% in accordance with TA267 Add Hydralazine & nitrate (especially if of African/Caribbean descent) Consider hydralazine & nitrate if intolerant of ACEI & ARB Digoxin for worsening HF* *Please refer to CG180 for recommendations on the use ofdigoxin in patients with atrial fibrillation If the person s egfr is 30-45 ml/min/1.73 m2, consider lower doses and/or slower titration of dose of ACE Inhibitors, ARBs, mineralocorticoid receptor antagonists,sacubitril-valsartan and digoxin. Ifthe person s egfr is <30 ml/min/1.73 m2, liaise with the renal physician.

Managing Heart Failure with Preserved Ejection Fraction NICE CHF Guideline NG106

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Preserved Ejection Fraction (HFPEF) Manage co-morbid conditions such as high blood pressure, atrial fibrillation, ischaemic heart disease, and diabetes mellitus in line with NICE guidance

Heart Failure diagnosed by the specialist Offer diuretics for the relief of congestive symptoms and fluid retention Heart Failure with Preserved Ejection Fraction (HFPEF) Manage co-morbid conditions such as high blood pressure, atrial fibrillation, ischaemic heart disease, and diabetes mellitus in line with NICE guidance Heart Failure with Reduced Ejection Fraction (HFREF) First line: Offer ACEI and BB Offer an MRA if symptoms continue All heart failure: Offer personalised, exercise-based cardiac rehabilitation programme, unless condition is unstable Specialist re-assessment Cardiac re-synchronisation therapy (CRT-P/D) in accordance with TA314 ICD in accordance with TA314 Replace ACEI (or ARB) by Sacubitril-Valsartan (if LVEF<35%) in accordance with TA388 If symptoms persist despite optimal first line therapy, seek specialist advice and consider one or more of the following options Add Ivabradine if in sinus rhythm with a HR of >75bpm and LVEF <35% in accordance with TA267 Add Hydralazine & nitrate (especially if of African/Caribbean descent) *Please refer to CG180 for recommendations on the use ofdigoxin in patients with atrial fibrillation Digoxin for worsening HF* Consider ARB if intolerant of ACEI Consider hydralazine & nitrate if intolerant of ACEI & ARB If the person s egfr is 30-45 ml/min/1.73 m2, consider lower doses and/or slower titration of dose of ACE Inhibitors, ARBs, mineralocorticoid receptor antagonists,sacubitril-valsartan and digoxin. Ifthe person s egfr is <30 ml/min/1.73 m2, liaise with the renal physician.

NICE - Cardiac Rehabilitation Offer people with heart failure a personalised, exercise-based cardiac rehabilitation programme, unless their condition is unstable. The programme: Should be preceded by an assessment to ensure that it is suitable for the person Should be provided in a format and setting (at home, in the community or in the hospital) that is easily accessible for the person Should include a psychological and educational component May be incorporated within an existing cardiac rehabilitation programme Should be accompanied by information about support available from healthcare professionals when the person is doing the programme

NICE Resource Impact -Cardiac Rehabilitation

NICE Resource Impact -Cardiac Rehabilitation

NICE Chronic Heart Failure Coronary revascularisation u1.8.1 Do not routinely offer coronary revascularisation to people who have heart failure with reduced ejection fraction and coronary artery disease. [2018]

NICE Chronic Heart Failure Salt and fluid restriction u 1.6.12 Do not routinely advise people with heart failure to restrict their sodium or fluid consumption. Ask about salt and fluid consumption and, if needed, advise as follows: u restricting fluids for people with dilutional hyponatraemia u reducing intake for people with high levels of salt and/or fluid consumption. Continue to review the need to restrict salt or fluid. [2018] u 1.6.13 Advise people with heart failure to avoid salt substitutes that contain potassium. [2018]

Clinical review (NICE CHF Guideline NG106) All people with chronic heart failure need monitoring. This monitoring should include: u a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status u a review of medication, including need for changes and possible side effects u an assessment of renal function [2010, amended 2018] u The frequency of monitoring should depend on the clinical status and stability of the person. The monitoring interval should be short (days to 2 weeks) if the clinical condition or medication has changed, but is needed at least 6-monthly for stable people with proven heart failure. [2003]

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