U.K. updates HF guidelines: NICE, but are they enough?

The U.K. National Institute for Health and Clinical Excellence (NICE) has updated its chronic heart failure (HF) guidelines to outline better management strategies of the disease. The guidelines focus on serum natriuretic peptide levels, echocardiography, drug therapy, cardiac resynchronization (CRT), implantable cardioverter-defibrillators (ICDs) and disease monitoring for HF patient management. Yet, an accompanying editorial questioned whether guidelines will be enough, adding that fully engaging the patient and focusing on values may be just as important.

NICE evaluates the need for guideline updates every three years. The recommendations, published in the Aug. 15 issue of the Annals of Internal Medicine, addressed the importance of telemonitoring for this patient population and also appropriate time limits within which patients should receive both echocardiography and clinical assessment.

For a diagnosis of HF, besides echo, clinicians should also consider chest radiography, peak flow measurement or spirometry and blood tests. For patients without previous MI, the guidelines recommend that patients undergo measurement of serum natriuretic peptide with subsequent echo.

The guidelines recommend that echo with a specialist evaluation be available within two weeks of patient presentation if patients have a history of MI or high serum natriuretic peptide levels. Echo should be performed no later than six weeks after presentation if the serum natriuretic peptide levels are increased but not high.

For treatment of the disease, clinicians should focus on managing comorbid conditions. NICE outlined that patients with left ventricular systolic dysfunction should receive both an ACE inhibitor and beta-blocker. However, if ACE inhibitors are not well tolerated, ARBs may be a good alternative. Patients with persistent symptoms should receive additional drug therapy, CRT or an ICD, but only after careful consideration.

“Heart failure is a chronic, progressive syndrome with an unpredictable and sometimes fluctuating clinical course,” wrote Jonathan Mant, MD, of the University of Cambridge in the U.K., and colleagues on the Guideline Development Group. “Monitoring this clinical course is potentially important to ensure that patients are receiving optimal therapy (which may require up-titration or down-titration).”

While the 2003 guidelines did not include monitoring the HF population, the current guidelines recommend that clinicians should “consider specialist monitoring of serum natriuretic peptide levels in patients (for example, persons in whom up-titration of pharmacologic therapy with such agents as ACE inhibitors and beta-blockers is problematic or those with a history of hospitalization for exacerbations of heart failure).”

The authors said that the current economic situation presents a hurdle to implementing these updated guidelines. However, “heart failure will be diagnosed earlier and more accurately in patients who are managed according to this guideline, and these patients will receive earlier therapy with agents known to improve survival and substantially reduce hospitalization rate,” they wrote.

In an accompanying AIM editorial, Pamela N. Peterson, MD, MSPH, and John S. Rumsfeld, MD, PhD, of the Denver Health Medical Center and the Denver VA Medical Center, questioned the effectiveness of guidelines. “Tough questions about guidelines persist: Is there enough evidence for recommendations? How prescriptive should they be? How should we apply recommendation to individual patients? And, given their wide availability over many years, why does healthcare remain plagued by gaps in 'guideline-concordant' care, variations in quality and unsustainable costs?”

Peterson and Rumsfeld noted that some of the recommendations by NICE will “fuel debate,” specifically the recommendation that patients without a history of MI have echo only if natriuretic peptides are elevated. “This may be questioned because of the utility of echocardiography for not only measuring left ventricular function but also for detecting structural or valvular heart disease, pulmonary hypertension, and pericardial effusion,” Peterson and Rumsfeld wrote.

“Simply put, if guideline recommendations are not applied in clinical practice, gaps between diagnostic and therapeutic advances and improved health outcomes will persist,” Peterson and Rumsfeld concluded. To improve outcomes, three steps must be taken: patients must be empowered, science and robust quality improvement must be leveraged and healthcare delivery must become the focus, they wrote.