SIGN’s updated guideline on chronic heart failure is the first to include recommendations on the new sacubitril/valsartan combination drug. It also discusses alternatives to BNP testing.
Key points for GPs
• Measure B-type natriuretic peptide (BNP) or NT-proBNP levels to decide whether echocardiography is indicated. Patients with suspected heart failure with BNP above 400pg/ml (NT-proBNP above 2,000pg/ml) can be referred for echo and specialist assessment within two weeks.
• Sacubitril/valsartan can be given to patients with reduced ejection fraction who are still symptomatic after treatment with an ACE inhibitor or ARB, and should replace the drug they are on. ACE inhibitors should be stopped for 36 hours before starting sacubitril/valsartan.
• If a patient with confirmed heart failure is intolerant of an ACE inhibitor, then they should be given an ARB.
• Only consider combination therapy with an ACE inhibitor and ARB if an aldosterone antagonist is not tolerated.
BNP testing may not be available for all GPs. In this case, the guideline suggests an ECG, although this is not as sensitive as a normal BNP/NT-proBNP in excluding heart failure.
Dr Chris Arden, a GPSI in cardiology in Southampton, says: ‘The guideline recommends an ECG only once heart failure is diagnosed, but ideally it should be included earlier in the diagnostic pathway as it is important in identifying other potential causes, in particular atrial fibrillation or bradyarrhythmias, as well as evidence of previous myocardial infarction (left bundle branch block, Q waves), which increase the likelihood that the symptoms are related to left ventricular systolic dysfunction.’
‘The guidance is clear that those who remain symptomatic on triple therapy (ACE inhibitor/ARB, β-blocker and aldosterone antagonist) should be switched to sacubitril/valsartan in place of their ACE inhibitor/ARB. But it is important that decisions on sacubitril/valsartan be taken with a heart failure specialist and that the ACE inhibitor is stopped for 36 hours beforehand.’