NICE update on management of chronic heart failure

A wider range of drugs should be considered for the management of chronic heart failure in adults, NICE has recommended in an overhaul of guidance published in its final version last week.

Under the update, clinicians are advised to prescribe four classes of medication at once rather than waiting for the dose of each to be titrated.

The recommendations state that patients with chronic heart failure with reduced ejection fraction should be offered an angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist (MRA) and an SGLT2 inhibitor together.

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This approach could save around 3,000 deaths and 5,500 hospital admissions through drugs being started earlier in the heart failure pathway, NICE has estimated.

However, a previous recommendation that prescribers should only initiate SGLT2 inhibitors under advice from a specialist has been removed after pushback at the consultation stage.

For people on the maximum tolerated dose of the four classes of drugs who continue to have symptoms of heart failure, practices can consider switching the ACE inhibitor to an angiotensin receptor-neprilysin inhibitor (ARNI), NICE added.

People who cannot tolerate ACE inhibitors, should be offered an ARNI, beta-blocker, MRA and SGLT2 inhibitor instead, the committee advised.

‘The guideline continues to recommend that primary care prescribers consider seeking advice from a heart failure specialist before starting an ARNI’, a NICE spokesperson confirmed.

The update means earlier use of the SGLT2 inhibitors empagliflozin and dapagliflozin than NICE has recommended before.

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It follows economic modelling from clinical trials and real-world data which suggests that early use of an MRA and SGLT2 inhibitor in combination with ACE inhibitor and a beta-blocker is cost-effective.

The committee said because the correct sequencing of medicines will vary between patients, the guidelines are moving away from introducing each medicine in turn to ‘treatment combinations for different scenarios’.

In those with preserved ejection fraction, the updated recommendations also advise considering an MRA and an SGLT2 inhibitor.

There is also new guidance on monitoring of renal function after starting an ACE inhibitor, ARNI, ARB or MRA.

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It states that renal function and electrolyte levels should be measured one to two weeks after starting treatment, one to two weeks after each dose increment, every three to six months once the maximum tolerated dose has been established and any time renal function may be compromised.

A version of this article was initially published by Pulse.