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Management of Chronic Heart Failure in Adults: Synopsis of the National Institute for Health and Clinical Excellence Guideline . Jonathan Mant , MD; abdallah al- mohammad , md ; Sharon Swain, BA, Phd ; and philippe laramee,dc,msc , for the guideline development group

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Management of Chronic Heart Failure in Adults: Synopsis of the National Institute for Health and Clinical Excellence Guideline

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Management of chronic heart failure in adults synopsis of the national institute for health and clinical excellence gui 1326491

Management of Chronic Heart Failure in Adults: Synopsis of the National Institute for Health and Clinical Excellence Guideline

Jonathan Mant, MD; abdallah al-mohammad, md; Sharon Swain, BA, Phd; and philippelaramee,dc,msc, for the guideline development group

Chris fontimayor ms-III

Mercer University

School of medicine

Dr. Rahimi

9/9/2011


Heart failure hf

Heart Failure (HF)

  • A common clinical syndrome representing the end-stage of a number of different cardiac diseases

  • Result of any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood

  • Two types

    • Systolic Dysfunction

    • Diastolic Dysfunction


Heart failure

Heart Failure

  • Symptoms – dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, confusion and memory loss in advanced stages, diaphoresis and cool extremities at rest

  • New York Heart Association (NYHA) Classification

    • Class I – symptoms only with vigorous activities

    • Class II – symptoms with moderate exertion

    • Class III – symptoms with normal daily activities

    • Class IV – symptoms at rest


National institute for health and clinical excellence nice

National Institute for Health and Clinical Excellence (NICE)

  • Develops clinical practice guidelines for the National Health Service of England and Wales

  • First guideline on HF in 2003

  • Target population: Non-pregnant adults with symptoms of chronic HF

  • Exclusion: Patients with acute HF or acute exacerbations of chronic HF

  • Updated every 3 years

    • Literature searches for new evidence, warnings from licensing agencies , and major changes in costs

    • Actively seek out the views of health care professionals and patients


Guideline development process

Guideline Development Process

  • Guideline development group (GDG)– general practitioners, specialist nurses, a consultant physician, consultant cardiologists, and 2 members representing patients and caregivers

  • Clinical question Literature review Evidence grading


High quality evidence for pharmacologic therapy

High Quality Evidence for Pharmacologic Therapy

  • ACE inhibitors and ß-blockers reduce morbidity and increase survival in patients with left ventricular systolic dysfunction

  • No difference exists between selective ß-blockers (ie metoprolol) and nonselective ß-blockers (ie carvedilol) on the combined end point of mortality and hospitalization

  • Combination therapy of ARBs and ACE inhibitors increases risk of hyperkalemia

  • Adding ARB to ACE inhibitor and ß-blocker reduces the mortality and hospitalization caused by HF


Invasive therapy recommendations

Invasive Therapy Recommendations

  • Patients who are at any stage of HF with left ventricular systolic dysfunction should be considered for an implantable cardioverter-defibrillator (ICD)

  • Criteria

    • Sustained ventricular tachycardia or non-sustained ventricular tachycardia that is inducible on electrophysiology testing if the left ventricular ejection fraction (LVEF) is less than 35%

    • QRS of duration of 120 ms or longer if the LVEF is less than 30%


Rehabilitation

Rehabilitation

  • Moderate quality evidence shows that exercise rehab reduces hospital admissions for HF and increases long-term quality of life

  • GDG recommends supervised group exercise programs with psychological and educational components


Monitoring patients with hf

Monitoring Patients With HF

  • Moderate quality evidence

    • Therapy guided by serum natriuretic peptide levels results in a reduction of hospitalizations due to HF

    • Therapy guided by serum natriuretic peptide levels reduces mortality in persons younger than 75

  • Cost effective analysis demonstrated that serial serum natriuretic peptide monitoring was cost effective when used by specialists

  • Significant heterogeneity of evidence for the use of telemonitoring in decreasing hospitalizations

    • GDG has no recommendation for telemonitoring


New evidence since the implementation of the 2010 nice guideline

New Evidence Since the Implementation of the 2010 NICE guideline

  • EMPHASIS-HF Study (Epleronone in Mild Patients Hospitalization and Survival Study in Heart Failure)

    • Significant reductions in hospitalization and mortality when epleronone therapy is started in patients hospitalized during the preceding 6 months or with persistent moderate elevation of serum natriuretic peptide levels (BNP≥250 ng/L)

  • SHIƒT (Systolic Heart Failure Treatment with the Iƒ Inhibitor Ivabradine Trial)

    • Ivabradine, Iƒ channel blocker in SA node, significantly reduces unplanned hospitalization and mortality in patients with HF due to left ventricular systolic dysfunction whose HR remains higher than 70bpm


Discussion

Discussion

  • NICE guidelines are broadly consistent with other international guidelines (ESC and AHA)

  • Benefits

    • Earlier diagnosis

    • Better management

      • Decreased morbidity and mortality

    • Cost-effective


Level of evidence

Level of Evidence


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