Prescribing Guidelines for HEART FAILURE

This guidance is not intended to replace NICE NG 106 Chronic heart failure (Sept 2018), but provides primary care prescribers with a summary of key points relevant in practice.

 

Aims of treatment

  • To relieve symptoms
  • To improve exercise tolerance
  • To reduce incidence of acute exacerbations
  • To reduce hospitalisations
  • To reduce mortality

 

First-line treatment

Offer both angiotensin-converting enzyme (ACE) inhibitors and a beta-blocker licensed for heart failure to all patients with heart failure with reduced ejection fraction. Use clinical judgement when deciding which drug to start first.

 

ACE Inhibitors (first-line treatment)

  • Do not offer ACE inhibitor therapy if there is a clinical suspicion of haemodynamically significant valve disease until the valve disease has been assessed by a specialist
  • Start ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose is reached
  • Measure serum sodium and potassium, and assess renal function, before and 1 to 2 weeks after starting an ACE inhibitor, and after each dose increment
  • Measure blood pressure before and after each dose increment of an ACE inhibitor. Follow the recommendations on measuring blood pressure, including measurement in people with symptoms of postural hypotension, in the NICE guideline on hypertension in adults
  • Once the target or maximum tolerated dose of an ACE inhibitor is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell
    Formulary recommended ACE inhibitors;
    • LISINOPRIL initially 2.5-5mg ONCE DAILY, titrated up to 30-35mg ONCE DAILY, or
    • RAMIPRIL initially 2.5mg ONCE DAILY (1.25mg if already prescribed a diuretic), titrated up to 10mg ONCE DAILY

    Monitoring: serum urea, creatinine, electrolytes and eGFR at initiation and after each dose increment

Alternative treatments if ACE inhibitors are not tolerated

  • Consider an ARB licensed for heart failure as an alternative to an ACE inhibitor for people who have heart failure with reduced ejection fraction and intolerable side effects with ACE inhibitors
  • Measure serum sodium and potassium, and assess renal function, before and after starting an ARB and after each dose increment
  • Measure blood pressure after each dose increment of an ARB. Follow the recommendations on measuring blood pressure, including measurement in people with symptoms of postural hypotension, in the NICE guideline on hypertension in adults
  • Once the target or maximum tolerated dose of an ARB is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell
  • If neither ACE inhibitors nor ARBs are tolerated, seek specialist advice and consider hydralazine in combination with nitrate for people who have heart failure with reduced ejection fraction
  • Formulary recommended ARB;
    • LOSARTAN initially 12.5mg ONCE DAILY, increased at 1 – 2 weekly intervals, to 50mg ONCE DAILY
    • CANDESARTAN initially 4mg ONCE DAILY, doubling the dose at intervals of no less than 2 weeks, to 32mg ONCE DAILY

    Monitoring: serum potassium, creatinine, & eGFR required at baseline, week 2, week 4, and monthly thereafter

Beta-blockers

  • Do not withhold treatment with a beta-blocker solely because of age or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease or chronic obstructive pulmonary disease
  • Introduce beta-blockers in a ‘start low, go slow’ manner. Assess heart rate and clinical status after each titration. Measure blood pressure before and after each dose increment of a beta-blocker
  • Switch people whose condition is stable and who are already taking a beta-blocker for a comorbidity (for example, angina or hypertension), and who develop heart failure with reduced ejection fraction, to a beta-blocker licensed for heart failure
  • Formulary recommended beta-blocker for heart failure;
    • BISOPROLOL initially 1.25mg ONCE DAILY, titrated according to response and tolerability to 10mg ONCE DAILY

    Where an alternative to bisoprolol is required, for example where there is intolerance or concern that unopposed beta-blockade may be undesirable;

    Carvedilol should be considered as the appropriate alternative beta-blocker for heart-failure patients. There is also a stronger evidence base for carvedilol in those patients with higher grades of heart failure and its use may be preferred in this situation. Prescribers should be aware that carvedilol requires twice-daily dosing and the implications of this for compliance with therapy should be taken into account when selecting a beta-blocker for heart failure.

    NB. Although doses of beta-blockers should be titrated to the maximum tolerated, a small dose of a beta-blocker is better than no beta-blocker at all.

Mineralocorticoid receptor antagonists (spironolactone, eplerenone)

  • Offer an MRA, in addition to an ACE inhibitor (or ARB) and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure
  • Measure serum sodium and potassium, and assess renal function, before and after starting an MRA and after each dose increment
  • Measure blood pressure before and after after each dose increment of an MRA. Follow the recommendations on measuring blood pressure, including measurement in people with symptoms of postural hypotension, in the NICE guideline on hypertension in adults
  • Once the target, or maximum tolerated, dose of an MRA is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell

Specialist treatment

Ivabradine

  • These recommendations are from NICE’s technology appraisal guidance on ivabradine for treating chronic heart failure
  • Ivabradine is recommended as an option for treating chronic heart failure for people:
    • with New York Heart Association (NYHA) class II to IV stable chronic heart failure with systolic dysfunction and
    • who are in sinus rhythm with a heart rate of 75 beats per minute (bpm) or more and
    • who are given ivabradine in combination with standard therapy including beta-blocker therapy, angiotensin-converting enzyme (ACE) inhibitors and aldosterone antagonists, or when beta-blocker therapy is contraindicated or not tolerated and
    • with a left ventricular ejection fraction of 35% or less
  • Ivabradine should only be initiated after a stabilisation period of 4 weeks on optimised standard therapy with ACE inhibitors, beta-blockers and aldosterone antagonists
  • Ivabradine should be initiated by a heart failure specialist with access to a multidisciplinary heart failure team. Dose titration and monitoring should be carried out by a heart failure specialist, or in primary care by either a GP with a special interest in heart failure or a heart failure specialist nurse
  • MHRA warnings on ivabradine: https://www.medicines.org.uk/emc/medicine/17188When using ivabradine to treat the symptoms of chronic angina:
    • only start ivabradine if the resting heart rate is at least 70 beats per minute
    • do not prescribe ivabradine with other medicines that cause bradycardia, such as verapamil, diltiazem, or strong CYP3A4 inhibitors
    • monitor patients regularly for atrial fibrillation. If atrial fibrillation occurs, carefully reconsider whether the benefits of continuing ivabradine treatment outweigh the risks
    • consider stopping ivabradine if there is no or only limited symptom improvement after 3 months.

    We also remind you of the following:

    •  ivabradine is indicated to treat symptoms of chronic angina in patients unable to tolerate or with a contraindication to beta-blockers – it can also be used in combination with beta-blockers in patients for whom an optimal beta-blocker dose is not enough 
    • the recommended starting dose is 5 mg twice daily
    • do not exceed the maximum maintenance dose of 7.5 mg twice daily

Sacubitril valsartan

  • These recommendations are from NICE’s technology appraisal guidance on sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction
  • Sacubitril valsartan is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people:
    • with New York Heart Association (NYHA) class II to IV symptoms and with a left ventricular ejection fraction of 35% or less and
    • who are already taking a stable dose of angiotensin-converting enzyme (ACE)
    • inhibitors or ARBs
  • Treatment with sacubitril valsartan should be started by a heart failure specialist with access to a multidisciplinary heart failure team. Dose titration and monitoring should be performed by the most appropriate team member as defined in NICE’s guideline on chronic heart failure in adults: diagnosis and management*
  • This guidance is not intended to affect the position of patients whose treatment with sacubitril valsartan was started within the NHS before this guidance was published. Treatment of those patients may continue without change to whatever funding arrangements were in place for them before this guidance was published until they and their NHS clinician consider it appropriate to stop

Hydralazine in combination with nitrate

  • Seek specialist advice and consider offering hydralazine in combination with nitrate (especially if the person is of African or Caribbean family origin and has moderate to severe heart failure [NYHA class III/IV] with reduced ejection fraction)

Digoxin

  • For recommendations on digoxin for people with atrial fibrillation see rate and rhythm control in the NICE guideline on atrial fibrillation
  • Digoxin is recommended for worsening or severe heart failure with reduced ejection fraction despite first-line treatment for heart failure. Seek specialist advice before initiating
  • Routine monitoring of serum digoxin concentrations is not recommended. A digoxin concentration measured within 8 to 12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non-adherence
  • The serum digoxin concentration should be interpreted in the clinical context as toxicity may occur even when the concentration is within the ‘therapeutic range’

 

Formulary recommendation;

  • DIGOXIN 62.5mcg – 125mcg ONCE DAILY (higher doses are rarely appropriate in heart failure not associated with AF)

Monitoring: serum urea & electrolytes, particularly potassium, creatinine, & eGFR required

Treating heart failure with reduced ejection fraction in people with chronic kidney disease

For people who have heart failure with reduced ejection fraction and chronic kidney disease with an eGFR of 30 ml/min/1.73 mor above:

  • offer the treatment outlined above and
  • if the person’s eGFR is 45 ml/min/1.73 m2 or below, consider lower doses and/or slower titration of dose of ACE inhibitors or ARBs, MRAs and digoxin.

For people who have heart failure with reduced ejection fraction and chronic kidney disease with an eGFR below 30 ml/min/1.73 m2, the specialist heart failure MDT should consider liaising with a renal physician.

Monitor the response to titration of medicines closely in people who have heart failure with reduced ejection fraction and chronic kidney disease, taking into account the increased risk of hyperkalaemia.

 

Other pharmacological interventions

Diuretics

  • Diuretics should be routinely used for the relief of congestive symptoms and fluid retention in people with heart failure, and titrated (up and down) according to need following the initiation of subsequent heart failure therapies
  • People who have heart failure with preserved ejection fraction should usually be offered a low to medium dose of loop diuretics (for example, less than 80 mg furosemide per day). People whose heart failure does not respond to this treatment will need further specialist advice

Calcium channel blockers. No calcium channel blocker is licensed for the treatment of heart failure.

Avoid verapamil, diltiazem and short acting dihydropyridine CCBs (imediate release nifedipine, nicardipine) in people who have  heart failure with reduced ejection fraction.

For those patients who develop heart failure or are at high risk of heart failure NICE CG127 (latest update 2016) recommends they should be changed to a thiazide-like diuretic in place of a CCB.

Where continuation of a dihydropyridine calcium channel blocker (amlodipine, etc) is considered essential for control of hypertension or angina, this may be justified where use of other therapies such as beta-blocker, ACE-inhibitor and diuretic has been optimised.

Anticoagulants

  • For people who have heart failure and atrial fibrillation, follow the recommendations on anticoagulation in the NICE guideline on atrial fibrillation. Be aware of the effects of impaired renal and liver function on anticoagulant therapies
  • In people with heart failure in sinus rhythm, anticoagulation should be considered for those with a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus

Vaccinations

  • Offer people with heart failure an annual vaccination against influenza
  • Offer people with heart failure vaccination against pneumococcal disease (only required once)

Contraception and pregnancy

  • In women of childbearing potential who have heart failure, contraception and pregnancy should be discussed. If pregnancy is being considered or occurs, specialist advice should be sought. Subsequently, specialist care should be shared between the cardiologist and obstetrician

Depression

Lifestyle advice

Salt and fluid restriction

  • Do not routinely advise people with heart failure to restrict their sodium or fluid consumption. Ask about salt and fluid consumption and, if needed, advise as follows:
    • restricting fluids for people with dilutional hyponatraemia
    • reducing intake for people with high levels of salt and/or fluid consumption
  • Continue to review the need to restrict salt or fluid
  • Advise people with heart failure to avoid salt substitutes that contain potassium

Smoking and alcohol

Air travel

  • Air travel will be possible for the majority of people with heart failure, depending on their clinical condition at the time of travel

Driving

  • Large Goods Vehicle and Passenger Carrying Vehicle licence: physicians should be up to date with the latest Driver and Vehicle Licensing Agency guidelines. Check the DVLA website for regular updates

Prescribing guideline post myocardial infarction –Drug therapy CG 172 secondary Prevention of MI

  • Offer all people who have had an acute MI treatment with the following medicines:
    • ACE (angiotensin-converting enzyme) inhibitor
    • dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
    • beta-blocker
    • statin.
  • Offer an assessment of left ventricular function to all people who have had an MI.
  • Titrate the ACE inhibitor dose upwards at short intervals (for example, every 12–24 hours) before the person leaves hospital until the maximum tolerated or target dose is reached. If it is not possible to complete the titration during this time, it should be completed within 4–6 weeks of hospital discharge.
  • Communicate plans for titrating beta-blockers up to the maximum tolerated or target dose – for example, in the discharge summary.

Offer an ACEI and aspirin to patients who have had an MI >12 months ago and also a β blocker to patients with LVSD whether symptomatic or not (new for 2013) ACE intolerant should be offered an ARB. Statins are recommended for all patients with established cardiovascular disease.

NICE does not specify preferred ACE and β blockers

Medicines with licence post MI

Ace creatnine clearance