NICE Implementation (Clinical Guideline 5 - Heart Failure)

Q1. Who should be managed in accordance with this guideline?

• 'Only patients when diagnosis is confirmed'.

Q2. How is this achieved in terms of cardiac assessment?

• 'Take a careful detailed history, and perform a clinical examination. These should be combined with tests to confirm the presence of heart failure and make a complete diagnosis.'

Q3. Why is echocardiography important?

• 'The full evaluation of heart failure is more than stating whether the syndrome is present or not; it requires consideration of the underlying abnormality of the heart, the severity of the syndrome and the aetiology.'
• 'Echocardiography should be performed because it consolidates the diagnosis and provides information on the underlying functional abnormality of the heart.'
• 'Echocardiography should be performed to exclude important valve disease, assess the systolic (and diastolic) function of the left ventricle and detect intra-cardiac shunts.'

Q4. At which point along the patient diagnostic pathway should echocardiography be performed?

Q5. Which patients should be referred to a specialist?

• 'Heart failure due to valve disease, diastolic dysfunction or any other cause except left ventricular systolic dysfunction.
• 'Severe heart failure.'
• 'One or more of the following co-morbidities (COPD/asthma/reversible airways disease, renal dysfunction, anaemia, thyroid disease, peripheral vascular disease, urinary frequency and gout).'
• 'Angina, atrial fibrillation or other symptomatic arrhythmia.'
• 'Women who are planning a pregnancy or who are pregnant.'
• 'Heart failure that does not respond to treatment.'
• 'Heart failure that can no longer be managed effectively in the home setting.'

Q6. Who should be performing and reporting echocardiography?

• 'Those experienced in doing so (trained to the relevant professional standards).'

Q7. What about those patients with existing diagnoses?

• 'The basis for historical diagnoses of heart failure should be reviewed, and only patients whose diagnosis is confirmed should be managed in accordance with this guideline.'
• 'If the diagnosis of heart failure is still suspected, but confirmation of the underlying cardiac abnormality has not occurred, then the patient should have appropriate further investigation.'