2 days ago
NICE Recommends Earlier Treatments for Chronic Heart Failure
Thousands of patients in England with early-stage chronic heart failure could benefit from earlier access to effective drug therapies under new draft guidance from the National Institute for Health and Care Excellence (NICE).
The guidance, which updates NICE's 2018 clinical recommendations, advises earlier treatment for heart failure with reduced ejection fraction ( HFrEF).
NICE said that clinical practice is changing and that medicines should be offered up to a year earlier in the treatment pathway.
The changes could prevent 3000 deaths and 5500 hospital admissions annually in England, the regulator estimated.
Earlier Use of Combination Therapies
The four pillars of treatment for HFrEF include:
Angiotensin-converting enzyme inhibitors (ACEIs)
Beta-blockers (BBs)
Mineralocorticoid receptor antagonists (MRAs)
Sodium-glucose cotransporter-2 (SGLT2) inhibitors
NICE said these drugs should be prescribed earlier, without the need to optimise the dose of any one medicine before introducing another.
SGLT2 inhibitors such as empagliflozin and dapagliflozin should now be offered at the start of the treatment pathway, rather than after other medications have been fully titrated – a process that could take over a year.
NICE also advised that angiotensin receptor neprilysin inhibitors (ARNIs) should be offered if a person cannot tolerate an ACEI, rather than only to patients stabilised on ACEIs or angiotensin receptor blockers (ARBs).
Both SGLT2 inhibitors and ARNIs could now be initiated by GPs with advice from heart failure specialists, potentially speeding up patient access.
Responding to Evolving Evidence
'We've been able to review the emerging evidence quickly to keep pace with changes in the treatment landscape and make recommendations that will widen access to effective treatments,' said Eric Power, deputy director in NICE's centre for guidelines.
He added that the new approach could help reduce emergency hospital admissions and improve quality of life for people living with heart failure.
Updated Diagnostic and Monitoring Advice
NICE also updated guidance on diagnosis and monitoring, particularly for iron deficiency and anaemia in patients with HFrEF.
Clinicians should:
Assess iron status and check for anaemia using transferrin saturation (TSAT), serum ferritin, and haemoglobin
Consider intravenous iron for patients with haemoglobin under 150 g/L and TSAT under 20% or ferritin under 100 ng/mL
If iron deficiency anaemia is found, alternative causes beyond heart failure should be investigated.
Revised Biomarker Recommendations
In addition, NICE advised clinicians to be aware that:
An NT-proBNP level of less than 400 nanogram per litre (47 pmol per litre) in an untreated person makes a diagnosis of heart failure less likely.
The level of serum natriuretic peptide does not differentiate between heart failure with preserved, mildly reduced, and reduced ejection fraction.
Obesity, African or African-Caribbean ethnic background, or treatment with a diuretic, an ACEI, an ARNI, an ARB, a beta-blocker, or a MRA could reduce serum natriuretic peptide levels.
High levels of natriuretic peptides may also be caused by non-cardiac conditions such as COPD, diabetes, sepsis, and liver or kidney disease.
Heart Failure Prevalence
Almost one million people in the UK are currently living with heart failure, with 200,000 new diagnoses each year.
The average age at diagnosis is 76. Rising life expectancy and obesity are driving the increased incidence and prevalence of the disease.
