NICE approves fast-tracked echocardiography for patients with suspected heart failure

By Lilian Anekwe

GPs should refer heart attack patients with suspected heart failure for urgent echocardiography, according to new draft recommendations by NICE.

In an update to its 2003 guidance on chronic heart failure, NICE has sought to beef up its recommendations on the diagnosis of the condition, which it now says must be assessed by a specialist within two weeks of GP referral.

Dr Fergus Macbeth, director of the NICE centre for clinical practice, said: ‘The original guideline recommended the use of echocardiography to help confirm a diagnosis of heart failure only after other tests were inconclusive. '

‘However, based on a review of new evidence about the best way for primary care physicians to diagnose heart failure published since the original NICE guideline, the updated draft recommends that people with suspected heart failure and who have had a previous heart attack should be referred urgently for echocardiography and specialist assessment.'

The draft guidance also recommends GPs treat patients with chronic heart failure with either ARBs, beta blockers or aldosterone antagonists, and isosorbide in combination with hydralazine to black patients who do not respond to treatment on other medications.

No upper age limit should be placed on patients requiring treatment, it stresses, and patients should be treated irrespective of age.

The draft guideline consultation runs until 10 March.

Diagnosis

· People with suspected heart failure and previous myocardial infarction should be referred urgently and have echocardiography and specialist assessment with 2 weeks.
· Refer patients with suspected heart failure and very high levels of serum natriuretic peptides for urgent echocardiography and specialist assessment within 2 weeks.
· Refer patients with suspected heart failure and raised levels of natriuretic peptides for echocardiography and specialist assessment.

Treatment

· Offer both angiotensin converting enzyme (ACE) inhibitors and beta- blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. The order in which these drugs are initiated should be based on clinical judgement.
· Offer an aldosterone antagonist to patients with heart failure due to left ventricular systolic dysfunction if moderate to severe symptoms persist despite optimal therapy with an ACE inhibitor and beta-blocker.
· Offer isosorbide/hydralazine to black patients who remain symptomatic with ACE inhibitors and beta-blockers.
· Do not substitute angiotensin II receptor antagonists for ACE inhibitors in patients with heart failure due to left ventricular systolic dysfunction unless there are intolerable side effects with ACE inhibitors.
· Consider adding an ARB to an ACE inhibitor and a beta-blocker in patients with heart failure due to left ventricular systolic dysfunction who remain symptomatic and are intolerant of aldosterone antagonists. This decision should be made by a specialist.

Source: Chronic heart failure (partial update): NICE draft guideline