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Latest NICE guideline for CHF focuses on BNP measurements, pacing therapy

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – An updated guideline on the management of chronic heart failure by the UK’s National Institute for Health and Clinical Excellence (NICE) addresses changes in diagnosis, pharmacologic treatment and pacing therapy, and disease monitoring since the first clinical guideline was issued in 2003.

The update was released in August 2010, and a synopsis is being published in the Annals of Internal Medicine for August 16. Lead author Dr. Jonathan Mant, at the University of Cambridge, and colleagues on the panel say the update makes “important changes to the previous guideline in England and Wales in diagnosis and treatment.”

Regarding diagnosis, increases in natriuretic peptide levels should guide assessment, they recommend. In patients without a history of MI, serum natriuretic peptide should be measured first; if levels are high, patients should see a specialist within 2 weeks and undergo echocardiography. On the other hand, echocardiography should be performed first in patients with a history of MI.

“In treatment, the guideline encourages increased use of beta-blockers and ACE inhibitors as first-line therapy in patients with heart failure and left ventricular systolic dysfunction and proposes options for second-line therapy (aldosterone antagonists, ARBs, or combination therapy with a nitrate and hydralazine),” the authors note.

However, for heart failure with preserved ejection fraction, the panel concluded that there is not enough evidence to recommend any specific pharmacologic therapies.

The treatment algorithm includes recommendations for cardiac resynchronization and implantable cardioverter-defibrillators. These can be considered for heart failure patients with left ventricular dysfunction who remain symptomatic with optimal medical therapy, depending on their ejection fraction and QRS duration, the guideline indicates.

The authors note that rehabilitation improves quality of life for patients with heart failure. “A supervised group exercise-based rehabilitation program that includes psychological and educational components should be offered to all patients with heart failure,” they advise, “ provided that they are stable and do not have a condition or device that would preclude an exercise-based program.”

Given the progressive nature of CHF, patient monitoring is important, Dr. Mant and colleagues note. Serial measurement of natriuretic peptide is useful in this regard for patients under 75 years old, according to the report, but not for older patients.

Overall, they conclude, “The NICE guidelines are broadly consistent with other international guidelines,” especially recommendations for treatment. “This fact is perhaps not surprising because the guidelines are all based on a substantial evidence base of high-quality randomized, controlled trials.”

The authors of an accompanying editorial note that the recommendations consider both clinical and cost effectiveness.

“Although this aspect may raise the most questions, and the National Health Service certainly differs from other health care systems, constrained resources are a shared concern for all,” they write. “Value is a critical concept in the current state of U.S. health care, should not be misconstrued as ‘rationing,’ and should not be ignored in guideline recommendations.”

Ann Intern Med 2011;155:252-259.