Improving the management of chronic heart failure

NICE has updated its guideline on heart failure. The principal changes from the 2003 guideline include more directive advice on how to improve the quality and timeliness of diagnosis. There is greater encouragement to use beta-blockers, more emphasis on rehabilitation, and better access to specialist advice--particularly at the time of diagnosis, admission to hospital, and where symptoms do not respond to first-line therapy with diuretics, ACE inhibitors and beta-blockers. A full history should be taken and clinical examination carried out. Patients with a past history of MI, or those with a high plasma BNP, should be referred to be seen within two weeks for echocardiography and specialist opinion. The specialist should determine: whether heart failure is present; its likely aetiology; precipitating factors; type of cardiac dysfunction; correctable causes; relevant comorbidity, and prognosis. Those with no history of MI but an elevated plasma BNP should be referred to be seen within six weeks for such assessment. Older adults, and patients with peripheral vascular disease, erectile dysfunction, diabetes mellitus, interstitial pulmonary disease and COPD without reversibility should be considered for beta-blocker therapy. A start low, go slow approach is recommended, with clinical review after each titration. Monitoring should include a clinical assessment, medication review, and a check of renal function as a minimum. Such a review should take place at least six monthly but may have to be much more frequent if there is a change in drug prescription or clinical status. Patients with stable heart failure should be offered a supervised group exercise-based rehabilitation programme designed for such patients. This should include a psychological and educational component, and could be incorporated within an existing cardiac rehabilitation programme.