NICE clinical guidelines
Issued: August 2010
CG108

Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg108

Introduction

This guidance updates and replaces 'Chronic heart failure' (NICE clinical guideline 5 (2003).

Heart failure is a complex clinical syndrome of symptoms and signs that suggest the efficiency of the heart as a pump is impaired. It is caused by structural or functional abnormalities of the heart. Some patients have heart failure due to left ventricular systolic dysfunction (LVSD) which is associated with a reduced left ventricular ejection fraction. Others have heart failure with a preserved ejection fraction (HFPEF). Most of the evidence on treatment is for heart failure due to LVSD. The most common cause of heart failure in the UK is coronary artery disease, and many patients have had a myocardial infarction in the past[1].

Around 900,000 people in the UK have heart failure. Almost as many have damaged hearts but, as yet, no symptoms of heart failure[2]. Both the incidence and prevalence of heart failure increase steeply with age, with the average age at first diagnosis being 76 years[3]. The prevalence of heart failure is expected to rise in future as a result of an ageing population, improved survival of people with ischaemic heart disease and more effective treatments for heart failure[4].

Heart failure has a poor prognosis: 30–40% of patients diagnosed with heart failure die within a year – but thereafter the mortality is less than 10% per year[5][6]. There is evidence of a trend of improved prognosis in the past 10 years. The 6-month mortality rate decreased from 26% in 1995 to 14% in 2005[7].

Patients on GP heart failure registers, representing prevalent cases of heart failure, have a 5-year survival rate of 58% compared with 93% in the age- and sex-matched general population[8]. On average, a GP will look after 30 patients with heart failure, and suspect a new diagnosis of heart failure in perhaps ten patients annually[9]. Heart failure accounts for a total of 1 million inpatient beddays – 2% of all NHS inpatient bed-days – and 5% of all emergency medical admissions to hospital. Hospital admissions because of heart failure are projected to rise by 50% over the next 25 years – largely as a result of the ageing population[10][11]. This is despite a progressive decline of the age-adjusted hospitalisation rate at 1–1.5% per annum since 1992/93[12].

For both patients and their carers heart failure can be a financial burden and have adverse effects on their quality of life.

Since we published 'Chronic heart failure: management of chronic heart failure in adults in primary and secondary care' (NICE clinical guideline 5) in 2003, new high-quality evidence from randomised controlled trials in diagnosis, treatment, rehabilitation and monitoring has been published. This guideline is an update of NICE clinical guideline 5 and replaces it. New recommendations have been made in line with the new evidence.

The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

New and updated recommendations are included on diagnosis, pharmacological treatment, monitoring and rehabilitation.

Recommendations are marked as [2003], [2003, amended 2010], [2006], [2007], [2010] or [new 2010].

[2003] indicates that the evidence has not been updated and reviewed since 2003

[2003, amended 2010] indicates that the evidence has not been updated and reviewed since 2003 but a small amendment has been made to the recommendation

[2006] applies to guidance from 'Implantable cardioverter defibrillators (ICDs) for the treatment of arrhythmias', NICE technology appraisal 95, published in 2006

[2007] applies to two recommendations from 'MI: secondary prevention', NICE clinical guideline 48 and guidance from 'Cardiac resynchronisation therapy for the treatment of heart failure', NICE technology appraisal 120, both published in 2007

[2010] indicates that the evidence has been reviewed but no changes have been made to the recommendation



[1] Petersen S, Rayner M, Wolstenholme J (2002) Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation

[2] Petersen S, Rayner M, Wolstenholme J (2002) Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation

[3] Cowie MR, Wood DA, Coats AJ et al.(1999) Incidence and aetiology of heart failure; a population-based study. European Heart Journal 20: 421–8

[4] Owan TE, Hodge DO, Herges RM et al. (2006) Trends in prevalence and outcome of heart failure with preserved ejection fraction. New England Journal of Medicine 355: 251–9

[5] Cowie MR, Wood DA, Coats AJ et al. (2000) Survival of patients with a new diagnosis of heart failure: a population based study. Heart 83: 505–10

[6] Hobbs FD, Roalfe AK, Davis RC et al. (2007) Prognosis of all-cause heart failure and borderline left ventricular systolic dysfunction: 5 year mortality follow-up of the Echocardiographic Heart of England Screening Study (ECHOES). European Heart Journal 28: 1128–34

[7] Mehta PA, Dubrey SW, McIntyre HF, Walker DM et al. (2009) Improving survival in the 6 months after diagnosis of heart failure in the past decade: population-based data from the UK. Heart 95: 1851–6

[8] Hobbs FD, Roalfe AK, Davis RC et al. (2007) Prognosis of all-cause heart failure and borderline left ventricular systolic dysfunction: 5 year mortality follow-up of the Echocardiographic Heart of England Screening Study (ECHOES). European Heart Journal 28: 1128–34

[9] Stewart S, Horowitz JD (2002) Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 105: 2861–6

[10] Stewart S, Horowitz JD (2002) Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 105: 2861–6

[11] Petersen S, Rayner M, Wolstenholme J (2002) Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation

[12] Mosterd A, Reitsma JB, Grobbee DE (2002) Angiotensin converting enzyme inhibition and hospitalisation rates for heart failure in the Netherlands, 1980 to 1999: the end of an epidemic? Heart 87: 75–6