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NICE issues guidance on responding to sudden heart failure

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Hospitals should ensure patients with suspected heart failure are seen by a specialist team, according to the National Institute for Health and Care Excellence.

In its latest guidance, NICE has recommended that anyone admitted with acute heart failure should “have early and continued input” from a multi-disciplinary team, led by a consultant and including specialist nurses.

“This guideline will help improve the care people receive when they are admitted to hospital as a result of acute heart failure”

Jayne Masters

This should usually take place in a cardiology ward but for the few patients whose needs prioritise care elsewhere, the specialist team could be used on an outreach basis, according to NICE.

By making sure this happened in all cases, survival rates will improve and so will the quality of life of heart failure patients, it said.

In addition, the guidance highlighted other “important components of care”, including immediate access to natriuretic peptide testing, timely access to echocardiography to show how well the heart is working, and use of proven drug therapies.

Unlike chronic heart failure, which is more common and which develops slowly over time and worsens gradually, acute heart failure develops suddenly.

NICE noted that, at present, the treatment of patients with acute heart failure varied. It said practice was not standardised across hospitals and different factors affected the decision on where to treat a patient, including the patient’s age, whether they had other illnesses and where beds were available.

It usually began in accident and emergency departments and continued in intensive care, high dependency or specialist coronary care units, the institute said. But other patients went on general medical wards or to cardiology wards, depending on treatment.

Jayne Masters, a lead heart failure nurse and member of the NICE guideline development group, said: “This guideline will help improve the care people receive when they are admitted to hospital as a result of acute heart failure.

“It will ensure that all acute heart failure patients are able to access the expertise of a multi-disciplinary heart failure team,” she said.

“It should also ensure that they are followed up in a timely manner by the appropriate clinician, thus reducing the likelihood of re-admission and complications and providing patients and carers with the reassurance of knowing who they can contact,” she added.

Dr Mike Knapton, associate medical director at the British Heart Foundation, said giving patients specialist diagnosis, treatment and care was crucial to saving lives and giving them a better quality of life.

British Heart Foundation

Mike Knapton

“We fully support this change in NICE guidance and for over 10 years the BHF has, and continues to, support heart failure specialist nurses in hospitals and the community,” he said.

Dr Knapton called on healthcare providers to put the changes in the NICE guidance into practice right away.

As well as the role of specialist management units, the guideline covers the role of echocardiography and early blood tests – natriuretic peptide testing – to diagnose acute heart failure, the use of breathing support, and drug treatments for acute heart failure.

It also addresses treatment after acute heart failure has been stabilised, including surgery, and starting drug treatments that are used in the management of chronic heart failure.


Key recommendations in the guideline are:

Organisation of care

  • All hospitals admitting people with suspected acute heart failure should provide a specialist heart failure team that is based on a cardiology ward and provides outreach services.
  • Ensure that all people being admitted to hospital with suspected acute heart failure have early and continuing input from a dedicated specialist heart failure team.

Diagnosis, assessment and monitoring

  • In people presenting with new suspected acute heart failure, use a single measurement of serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NT-proBNP])ii and the following thresholds to rule out the diagnosis of heart failure:

BNP less than 100 ng/litre

NT-proBNP less than 300 ng/litre

  • In people presenting with new suspected acute heart failure with raised natriuretic peptide levels, perform transthoracic Doppler 2D echocardiography to establish the presence or absence of cardiac abnormalities.
  • In people presenting with new suspected acute heart failure, consider performing transthoracic Doppler 2D echocardiography within 48 hours of admission to guide early specialist management.

Treatment after stabilisation

  • In a person presenting with acute heart failure who is already taking beta-blockers, continue the beta-blocker treatment unless they have a heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock.
  • Start or restart beta-blocker treatment during hospital admission in people with acute heart failure due to left ventricular systolic dysfunction, once their condition has been stabilised – for example, when intravenous diuretics are no longer needed.
  • Ensure that the person’s condition is stable for typically 48 hours after starting or restarting beta-blockers and before discharging from hospital.
  • Offer an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker if there are intolerable side effects) and an aldosterone antagonist during hospital admission to people with acute heart failure 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.
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