What are the management guidelines for Heart Failure (HF) according to NICE guidelines?

Heart Failure Management Based on NICE Guidelines

Core Treatment Approach for HF with Reduced Ejection Fraction (HFrEF)

Patients with left ventricular systolic dysfunction should receive both an ACE inhibitor and a β-blocker as first-line therapy, initiated simultaneously rather than sequentially. 1

First-Line Pharmacological Therapy

• ACE Inhibitors or ARBs: Start immediately upon diagnosis in all patients with HFrEF unless contraindicated, as they reduce mortality and hospitalization 1
• Beta-Blockers: Initiate concurrently with ACE inhibitors (not sequentially) to reduce mortality and sudden death risk 1
• Diuretics: Use for symptomatic relief of fluid retention and congestion; titrate to achieve euvolemic state 1
• SGLT2 Inhibitors: Now considered a fourth pillar of GDMT alongside ACE inhibitors, beta-blockers, and MRAs for mortality reduction 1, 2

Second-Line and Additional Therapies

• Mineralocorticoid Receptor Antagonists (MRAs): Add spironolactone for patients with persistent NYHA class III-IV symptoms despite first-line therapy, with preserved renal function and normal potassium 1
• Angiotensin Receptor-Neprilysin Inhibitor (ARNI): Consider sacubitril/valsartan as replacement for ACE inhibitors in patients who remain symptomatic despite optimal treatment 1
• Digoxin: May be initiated at any time to reduce symptoms and enhance exercise tolerance, particularly useful for rate control in atrial fibrillation 1

Alternative Therapies for Intolerance

• ARBs: Use if ACE inhibitors are not tolerated due to cough or angioedema 1
• Hydralazine plus Nitrate: Reserve for patients intolerant of both ACE inhibitors and ARBs due to hypotension or renal insufficiency 1

HF with Preserved Ejection Fraction (HFpEF)

For HFpEF, focus on managing comorbid conditions (hypertension, ischemic heart disease, diabetes) and use diuretics for fluid retention, as specific disease-modifying therapies have limited evidence. 1

• Diuretics: Use judiciously to reduce congestion and improve symptoms 1, 3
• SGLT2 Inhibitors: Consider as disease-modifying therapy based on recent positive trials 3
• Comorbidity Management: Prioritize aggressive treatment of hypertension, coronary disease, and diabetes 1

Concomitant Conditions Management

Hypertension

• Control systolic and diastolic hypertension according to guidelines using HF medications that also treat hypertension 1

Atrial Fibrillation

• Anticoagulation: Mandatory for CHA2DS2-VASc score ≥2 (men) or ≥3 (women); prefer direct oral anticoagulants over warfarin 1
• Rate Control: Use beta-blockers as first-line; amiodarone if beta-blockers contraindicated 1
• Rhythm Control: Consider AF ablation for symptomatic patients to improve quality of life 1

Coronary Artery Disease

• Medical Therapy: Nitrates and beta-blockers for angina management 1
• Revascularization: Consider surgical revascularization in selected patients with EF ≤35% and suitable anatomy to improve symptoms and mortality 1

Iron Deficiency

• Intravenous Iron: Reasonable for patients with HFrEF and iron deficiency (with or without anemia) to improve functional status and quality of life 1

Diabetes

• SGLT2 Inhibitors: Recommended for dual benefit of glycemic control and HF mortality reduction 1

Device Therapy

• Implantable Cardioverter-Defibrillator (ICD): For patients with history of sudden death, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia 1
• Cardiac Resynchronization Therapy (CRT): Consider according to specific criteria for eligible patients 1

Interventions NOT Recommended

Avoid these therapies as they provide no benefit or cause harm: 1, 4

• Calcium channel blockers (diltiazem, verapamil) - increase HF worsening and hospitalization 4
• NSAIDs and COX-2 inhibitors - increase HF worsening risk 4
• Long-term intermittent intravenous positive inotropic therapy 1
• Nutritional supplements (coenzyme Q10, carnitine, taurine, antioxidants) 1, 4
• Hormonal therapies (growth hormone, thyroid hormone) 1, 4
• Triple RAAS blockade (ACE inhibitor + ARB + MRA) - increases renal dysfunction and hyperkalemia 4

Practical Implementation Algorithm

Step 1: Confirm Diagnosis and Classify

• Measure LVEF to distinguish HFrEF (<40%) from HFpEF (>40%) 1
• Assess NYHA functional class and volume status 1

Step 2: Initiate Core Therapy Simultaneously (for HFrEF)

• Start ACE inhibitor AND beta-blocker together (not sequentially) 1
• Add diuretic if fluid retention present 1
• Initiate SGLT2 inhibitor as fourth pillar 1, 2

Step 3: Uptitrate to Target Doses

• Increase doses every 2-4 weeks as tolerated to evidence-based target doses 2
• Monitor renal function, potassium, and blood pressure with each change 5

Step 4: Add MRA if Persistent Symptoms

• For NYHA class III-IV symptoms despite optimal first-line therapy 1
• Check potassium and creatinine before and after initiation 5

Step 5: Consider ARNI Substitution

• Replace ACE inhibitor with sacubitril/valsartan if symptoms persist on maximal therapy 1
• Ensure 36-hour washout period from ACE inhibitor 5

Step 6: Specialist Referral

• Refer for persistent symptoms despite optimal medical therapy for consideration of device therapy, advanced therapies, or enrollment in disease management programs 1, 2

Common Pitfalls to Avoid

• Sequential rather than simultaneous initiation: Start ACE inhibitor and beta-blocker together, not one after the other 1
• Underdosing: Most patients receive suboptimal doses; uptitrate aggressively to target doses proven in trials 6
• Withholding beta-blockers during mild decompensation: Continue unless severe fluid overload or requiring IV inotropes 3
• Stopping GDMT during hospitalization: Maintain ACE inhibitors/ARBs and beta-blockers unless hemodynamically unstable 3
• Delaying SGLT2 inhibitor initiation: This is now a core therapy, not an add-on; start early 1, 2

Monitoring Requirements

• Renal function and electrolytes: Check within 1-2 weeks after initiating or uptitrating RAAS inhibitors or MRAs 5
• Blood pressure: Monitor for hypotension, especially with multiple agents; adjust diuretics and other antihypertensives before reducing GDMT 5
• Daily weights: Patient self-monitoring to detect early fluid retention 1, 2
• Potassium: Particularly important with MRA use; hold if >5.5 mEq/L 5