Although the updated heart failure guidelines from the U.K.’s National Institute for Health and Clinical Excellence (NICE) are broadly consistent with similar guidelines from Europe and the U.S., outside experts are questioning several key details of the update.

-Team@CMHF

• Much of the controversy revolves around the relative weight given to echocardiography and natriuretic peptides in the diagnosis and treatment of heart failure.
• The updated NICE guidelines recommend that for the diagnosis of heart failure in patients with no history of MI, echocardiography should be used only if natriuretic peptides are raised.
• ESC and ACC/AHA guidelines recommend that all patients with the signs and symptoms of heart failure should have an echocardiogram.
• The NICE position may be questioned because of the utility of echocardiography for not only measuring left ventricular function but also for detecting structural or valvular heart disease, pulmonary hypertension, and pericardial effusion.
• Serial natriuretic peptide monitoring is cost-effective only when performed by specialists and only when used in select heart failure patients, some may argue that natriuretic peptide monitoring should be used more broadly.
• Since the updated NICE guidelines base their recommendations regarding ICDs on cost-effectiveness calculations as well as on clinical trial evidence, they therefore differ from guidelines from other organizations that do not explicitly incorporate economic factors.

Press release from Annals of Internal Medicine

Updated NICE Guidelines not so fast to recommend Echocardiography in all patients

• According to the updated guidelines, patients should be categorized by a symptom assessment and health history.
• Patients with no history of myocardial infarction should undergo measurement of serum natriuretic peptide followed by echocardiography only if natriuretic peptide levels are elevated, as symptoms of heart failure have little bearing on diagnosis.
• Patients with a history of heart attack should proceed directly to echocardiography.
• Patients who are diagnosed with heart failure with left ventricular systolic dysfunction should be treated with beta blockers and ACE inhibitors.
• A second option for treatment would be aldosterone antagonists, ARBs, or combination therapy with nitrate and hydralazine.
• The guideline recommends group exercise-based rehabilitation programs regardless of contraindications.
• Clinicians in the US could prevent nearly 68,000 deaths a year if they followed six heart failure guideline recommendations.
• It is also important to involve patients in the care process, clinical decisions should be based on guideline recommendations, but individualized according to a patient’s risk-benefit ratio, and incorporate patient preferences through shared decision-making

For further reading log on to

http://www.forbes.com/sites/larryhusten/2011/08/17/details-of-updated-uk-heart-failure-guidelines-raise-some-eyebrows/