Heart failure

NICE publishes updated guidance on the management of acute heart failure

NICE has published updated guidelines on the diagnosis and management of acute heart failure (AHF). The guideline includes recommendations on diagnosis, evaluation and monitoring, initial pharmacological and non-pharmacological treatment, post-stabilization management and the use of mechanical devices.

Diagnostic

The guidelines say that all hospitals admitting people with suspected AHF should provide a specialist heart failure team based on a cardiology service, and patients admitted to hospital with suspected AHF should benefit from the contribution. early and continuous from a specialized team dedicated to heart failure.

A follow-up clinical assessment should be undertaken by a member of the heart failure specialist team within two weeks of discharge.

In people with suspected new AHF, a single measurement of serum natriuretic peptides (BNP or NT-proBNP) should be used. Thresholds to rule out heart failure are BNP

In people with suspected new AHF with elevated levels of natriuretic peptides, 2D transthoracic Doppler echocardiography should be performed (preferably within 48 hours) to establish the presence or absence of cardiac abnormalities.

Pulmonary artery catheterization should not be routinely offered to patients with IAF.

Initial pharmacological treatment

Patients should not be routinely offered opioids, nitrates, sodium nitroprusside, inotropes, or vasopressors.

Intravenous (IV) nitrates may continue to be used in specific circumstances, such as in people with concomitant myocardial ischemia, severe hypertension, or regurgitating aortic or mitral valve disease, in a level 2 care setting. .

Inotropes or vasopressors may be considered for people with IAF who have potentially reversible cardiogenic shock, but they should only be given in a cardiac ward or high dependency unit or other level 2 setting.

Intravenous diuretic therapy is recommended, starting with a bolus or infusion strategy. For those admitted who are already taking a diuretic, a higher dose of the diuretic may be considered, unless there are concerns about the patient’s adherence to diuretic therapy prior to admission.

Initial non-pharmacological treatment

Continuous positive airway pressure (CPAP) or noninvasive positive airway pressure (NPVPV) should be avoided in patients with AHF and cardiogenic pulmonary edema. However, for patients who present with cardiogenic pulmonary edema with severe dyspnea and acidemia, consider initiating non-invasive ventilation without delay.

Invasive ventilation can be used in people with AHF and respiratory failure or reduced consciousness or physical exhaustion.

Ultrafiltration should not be offered routinely, but may be considered in people with confirmed diuretic resistance.

After stabilization

After stabilization, patients on beta blockers should continue treatment, provided the heart rate is> 50 beats per minute and there is no second or third degree atrioventricular block or shock.

For hospitalized patients who no longer require IV diuretics, start or restart AHF beta-blocker therapy due to left ventricular systolic dysfunction, and ensure the patient’s condition is stable for 48 hours before departure.

Offer an angiotensin converting enzyme inhibitor (or an angiotensin receptor blocker if this cannot be tolerated) and an aldosterone blocker for people with IAF and ventricular ejection fraction. reduced left. If the angiotensin converting enzyme inhibitor (or angiotensin receptor blocker) is not tolerated, an aldosterone antagonist should still be offered.

This update to the AHF guidelines includes the removal of the guidelines for valve surgery and percutaneous intervention. Recommendations for these interventions are now available in the NICE guidelines on heart valve disease.

At an early stage, discussions should be conducted with a center providing mechanical circulatory support in relation to patients with severe potentially reversible AHI or those who are potential candidates for transplantation.

Research

The guideline also calls for research into new approaches to the management of AF.

It indicates that randomized controlled trials are needed to determine whether adding low-dose dopamine or a thiazide diuretic to standard therapy leads to more clinically and cost-effective decongestion in people admitted to hospital for treatment of ” decompensated heart failure. The study should aim to investigate the diuretic effect of dopamine as well as its effects on kidney function.

In addition, NICE is requesting a study comparing results with the intra-aortic balloon pulse pump and those seen with the use of inotropes / vasopressors in people with AHF and hypoperfusion syndrome.

A randomized trial is also needed to determine whether ultrafiltration is more clinically effective and cost effective than conventional diuretic therapy for people admitted to hospital with decompensated heart failure.

Acute heart failure: diagnosis and management: clinical guideline [CG187]. National Institute for Health and Excellence in Care. 2021 November 17.


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