NICE has updated its evidence based guidance on managing chronic heart failure. This article looks at the implications of these changes for nursing practice
Chronic heart failure affects about 900,000 people in the UK. Symptoms are often debilitating and prognosis can be poor, but with appropriate management and treatment, people can have a longer and better quality of life.
In July 2003, the original chronic heart failure NICE Guideline gave practical guidance as to the diagnosis and management for adults with heart failure. The updated version incorporates the latest evidence outlining recommended pathways for best practice. The focus is on initial rapid and accurate diagnosis by a specialist. Thereafter, timely, holistic care is to be provided by heart failure teams.
The new guideline has implications for all nurses involved in the care of adults with heart failure. With the number of people affected by heart failure predicted to increase, the importance of the guideline cannot be over-emphasised.
Presentation and assessment
The guidance states that all patients with a history of a previous heart attack who present with clinical signs or symptoms of heart failure such as breathlessness, fluid retention or fatigue should be referred for urgent echocardiography and specialist assessment, which should be provided within two weeks. People with heart failure are likely to present routinely through coronary heart disease clinics, often led by practice nurses, so it is important to identify these patients and ensure appropriate referrals are made.
For patients without previous history of a heart attack where heart failure is suspected, a blood test for serum natriuretic peptide (BNP) must be arranged. If the BNP is within the normal range, heart failure is unlikely in an untreated patient. However, if it is elevated the patient must be referred for specialist assessment.
The specialist clinical review will include careful assessment and echocardiography. The speed with which the specialist clinical assessment and echocardiography are delivered is dependent on the level of the serum natriuretic peptide. If heart failure is confirmed as a cause for the symptoms, aetiology will be reviewed, appropriate pharmacological treatment initiated and future care planned.
The specialist will lead a multidisciplinary heart failure team of professionals with appropriate competencies from primary and secondary care. The heart failure team is best placed to ensure optimisation of medical therapies, continuation of monitoring and support for both the patient and carers.
Cardiac rehabilitation already benefits many patients. Patients with heart failure are no exception and many will benefit greatly from this service. It is recognised that adjustments to existing services or new service provision will be necessary to ensure that this is available to all.
Unfortunately, despite provision of best care, patients will continue to require admission to hospital with, or as a direct result of heart failure. The new guidance states that inpatient care of these patients should be guided by a specialist in heart failure. For ward staff, the responsibility is to ensure patients with known or suspected heart failure receive specialist review while in hospital. By ensuring patients receive optimal care and appropriate support, further readmissions can be reduced.
When considering the advised pharmacological treatment of heart failure due to left ventricular systolic dysfunction there have been several changes to the guidance since 2003. All patients should continue to be offered both angiotensin-converting enzyme inhibitors and beta blockers licensed for heart failure. Either drug can be started first depending on clinical need. If the patient remains symptomatic, despite optimal doses of ACE-inhibitor and beta blocker, the patient should be referred to the specialist and the heart failure multi-disciplinary team.
The specialist should consider adding an aldosterone antagonist licensed for heart failure, an angiotensin II receptor antagonists licensed for heart failure or a combination of nitrates and hydralazine. The latter is particularly helpful in patients of African or Caribbean origin. When truly intolerant of ACE-inhibitors, an angiotensin II receptor antagonist can be considered. Triple therapy with ACEI, ARB and aldosterone antagonist is not advised.
Since the 2003 guideline we have seen evidence of improved care and provision of services for heart failure patients. However, availability of services is not equal in all areas. Hopefully, the new NICE guideline will encourage health authorities to establish equal service provision, thereby ensuring availability for all. The introduction of a time frame and requirement for all heart failure patients to receive specialist review will, I believe, go a long way to improve the care that heart failure patient’s receive. With the emphasis on specialist heart failure teams spanning primary and secondary care we are likely to see improved co-ordination resulting in the best use of resources. This may entail some reorganisation of existing services and there will be commissioning implications. However, improved care will ultimately improve patients’ quality of life and reduce the need for hospitalisation.
The guideline is available for download atwww.nice.org.uk/cg108
AUTHOR Jane Gilmour, BSc, RGN, is a specialist nurse in chronic heart failure, Luton and Dunstable NHS Foundation Trust and a member of the NICE guideline development group.