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

Treating heart failure

ACE=angiotensin-converting enzyme; ARB=angiotensin II receptor blockers; ICD=implantable cardioverter defibrillator; CRT=cardiac resynchronization therapy.
^* For more information on drug treatment see appendix D of the NICE guideline and 'Chronic kidney disease' (NICE clinical guideline 73). ^†Consider an ICD in line with 'Implantable cardiovascular defibrillators for arrhythmias' (NICE technology appraisal guidance 95). ^‡NYHA class III–IV. ^§Not all ARBs are licensed for use in heart failure in combination with ACE inhibitors. |NYHA class II–III. ^¶This does not include mixed race. For more information see the full guideline at www.nice.org.uk/guidance/CG108. ^**Consider CRT in line with 'Cardiac resynchronisation therapy for the treatment of heart failure' (NICE technology appraisal guidance 120).

Lifestyle advice for patients with heart failure

• Exercise
  • see ‘Rehabilitation’ below
• Smoking
  • strongly advise patients not to smoke
  • consider referral to smoking cessation services
• Alcohol
  • advise patients with alcohol-related heart failure to abstain
  • discuss consumption with other patients and tailor advice to clinical circumstances
• Sexual activity
  • be prepared to broach sensitive issues such as sexual activity
• Vaccination
  • offer:
    • an annual vaccination against influenza
    • a one-off vaccination against
      pneumococcal disease
• Air travel
  • consider clinical circumstances when advising about air travel
• Driving regulations
  • check the latest Driver and Vehicle Licensing Agency guidelines for drivers of large goods and passenger carrying vehicles (see www.dft.gov.uk/dvla for regular updates)

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

Monitoring

Clinical review

• Monitor all patients. Include:
  • clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status
  • a review of drug treatment, including need for changes and possible side effects
  • a minimum of serum urea, electrolytes, creatinine and eGFR*
• When a patient is admitted to hospital because of heart failure, seek advice on their management plan from a specialist in heart failure

Rehabilitation

• Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure
  • ensure the patient is stable and does not have a condition (such as uncontrolled ventricular response to atrial fibrillation, or uncontrolled hypertension) or device (for example, a high-energy pacing device set to be activated at rates achieved during exercise) that would preclude the programme
  • include a psychological and educational component in the programme
  • the programme may be incorporated within an existing cardiac rehabilitation programme

Discharge planning and long-term care

Discharge planning

• Discharge patients from hospital only when their condition is stable and their management plan optimised. When considering the timing of discharge take account of:
  • patient and carer wishes
  • level of care and support available in the community

^* This is a minimum. Patients with comorbidities or co-prescribed medications will require further monitoring. Monitoring serum potassium is particularly important if a patient is taking digoxin or an aldosterone antagonist

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
guidance.nice.org.uk/CG108

National Institute for Health and Care Excellence. management of chronic heart failure in adults in primary and secondary care. August 2010