The guideline includes recommendations on diagnosis, assessment and monitoring, initial pharmacological and nonpharmacological treatment, management after stabilisation, and the use of mechanical devices

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NICE has published updated Clinical Guideline 187 on the diagnosis and management of acute heart failure (AHF). The guideline includes recommendations on diagnosis, assessment and monitoring, initial pharmacological and nonpharmacological treatment, management after stabilisation, and the use of mechanical devices.

Diagnosis

The guidance states that all hospitals admitting people with suspected AHF should provide a specialist heart failure team based on a cardiology ward, and patients admitted to hospital with suspected AHF should have early and continuing input from a dedicated specialist heart failure team.

A follow‑up clinical assessment should be undertaken by a member of the specialist heart failure team within 2 weeks of discharge.

In people presenting with new suspected AHF, a single measurement of serum natriuretic peptides (brain natriuretic peptide [BNP] or N-terminal [NT]‑proBNP) should be used. Thresholds to rule out heart failure are BNP <100 ng/l or NT‑proBNP <300 ng/l.

In people presenting with new suspected AHF with raised natriuretic peptide levels, a transthoracic Doppler two-dimensional echocardiography should be performed (preferably within 48 hours) to establish the presence or absence of cardiac abnormalities.

Pulmonary artery catheterisation should not be routinely offered to patients with AHF.

Initial pharmacological treatment

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

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

Inotropes or vasopressors can be considered for people with AHF with potentially reversible cardiogenic shock, but these should only be administered in a cardiac care unit, high-dependency unit, or alternative level-2 setting.

Intravenous diuretic therapy is recommended, starting with either a bolus or infusion strategy. For people who have been admitted are are already taking a diuretic, a higher dose of diuretic can be considered unless there are concerns about patient adherence to diuretic therapy before admission.

Initial nonpharmacological treatment

Continuous positive airway pressure or noninvasive positive pressure ventilation should be avoided in patients with AHF and cardiogenic pulmonary oedema. However, for patients who have cardiogenic pulmonary oedema with severe dyspnoea and acidaemia, consider starting noninvasive ventilation without delay.

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

Ultrafiltration should not be routinely offered, but can be considered for people with confirmed diuretic resistance.

After stabilisation

After stabilisation, patients on beta-blockers should continue treatment, provided that heart rate is greater than 50 beats per minute and in the absence of second- or third-degree atrioventricular block or shock.

For inpatients who no longer require IV diuretics, beta‑blocker treatment for AHF due to left ventricular systolic dysfunction should be started or restarted, and it should be ensured that the patient’s condition is stable for 48 hours before discharging.

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

This updated guidance on AHF sees the removal of guidance on valvular surgery and percutaneous intervention. Recommendations on these interventions are now available in NICE Guideline 208 on heart valve disease.

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

Research

The guideline also calls for research on new approaches to the management of AHF.

It says that randomised controlled trials are needed to investigate whether the addition of low‑dose dopamine or a thiazide diuretic to standard therapy leads to more clinically and cost-effective decongestion in people admitted to hospital for the treatment of decompensated heart failure. The study should aim to investigate the diuretic effect of dopamine, as well as effects on renal function.

In addition, NICE is calling for a study comparing outcomes with intra‑aortic balloon counter‑pulsation pump with or without the use of inotropes/vasopressors in people with AHF and hypoperfusion syndrome.

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

This article originally appeared on Univadis, part of the Medscape Professional Network.

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