NICE guidance - acute heart failure (AHF)

Last reviewed 01/2018

NICE Guidance - Summary of Main Features of Acute Heart Failure guidance

Use of BNP in acute heart failure:

  • if suspected acute heart failure, use a single measurement of serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NT-proBNP]) and the following thresholds to rule out the diagnosis of heart failure:
    • BNP less than 100 ng/litre
    • NT-proBNP less than 300 ng/litre

  • if presenting with new suspected acute heart failure with raised natriuretic peptide levels, perform transthoracic Doppler 2D echocardiography to establish the presence or absence of cardiac abnormalities
    • consider performing transthoracic Doppler 2D echocardiography within 48 hours of admission to guide early specialist management

Initial pharmacological treatment

  • intravenous diuretic therapy
    • for people already taking a diuretic, consider a higher dose of diuretic than that on which the person was admitted unless there are serious concerns with patient adherence to diuretic therapy before admission
      • closely monitor the person's renal function, weight and urine output during diuretic therapy
  • intravenous nitrates
    • if used in specific circumstances, such as for people with concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease, monitor blood pressure closely
  • consider inotropes or vasopressors in people with acute heart failure with potentially reversible cardiogenic shock

Initial non-pharmacological treatment

  • if a person has cardiogenic pulmonary oedema with severe dyspnoea and acidaemia consider starting non-invasive ventilation without delay:
    • at acute presentation or
    • as an adjunct to medical therapy if the person's condition has failed to respond
  • consider invasive ventilation in people with acute heart failure that, despite treatment, is leading to or is complicated by:
    • respiratory failure or
    • reduced consciousness or physical exhaustion
  • consider ultrafiltration for people with confirmed diuretic resistance

Treatment after stabilisation

  • beta blockers
    • in a person presenting with acute heart failure who is already taking beta-blockers
      • continue the beta-blocker treatment unless they have a heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock
      • start or restart beta-blocker treatment during hospital admission in people with acute heart failure due to left ventricular systolic dysfunction, once their condition has been stabilised - for example, when intravenous diuretics are no longer needed
      • ensure that the person's condition is stable for typically 48 hours after starting or restarting beta-blockers and before discharging from hospital
  • ACEI/ARB or aldosterone antagonist
    • offer an angiotensin-converting enzyme inhibitor (or angiotensin receptor blocker if there are intolerable side effects) and an aldosterone antagonist during hospital admission to people with acute heart failure and reduced left ventricular ejection fraction. If the angiotensin-converting enzyme inhibitor (or angiotensin receptor blocker) is not tolerated an aldosterone antagonist should still be offered
  • closely monitor the person's renal function, electrolytes, heart rate, blood pressure and overall clinical status during treatment with beta-blockers, aldosterone antagonists or angiotensin-converting enzyme inhibitors

Valvular surgery and percutaneous intervention

  • offer surgical aortic valve replacement to peoplewith heart failure due to severe aortic stenosis assessed as suitable for surgery
  • consider transcatheter aortic valve implantation (TAVI) in selected people with heart failure caused by severe aortic stenosis, who are assessed as unsuitable for surgical aortic valve replacement
  • consider surgical mitral valve repair or replacement for people with heart failure due to severe mitral regurgitation assessed as suitable for surgery