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Playing NICE with the Acute Heart Failure Guidance

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Playing NICE with the Acute Heart Failure Guidance
nice ahf feat

These are the current NICE guidance for patients presenting with Acute Heart Failure(AHF). The problem with these guidelines is the definition of AHF. No mention of whether AHF is the same as ADHF (decompensated) but I'm guessing they are commenting on patients who present early with mild symptoms of heart failure. But for arguments sake, because Emergency Physicians are hammers and this looks like a nice enough nail, I thought I'd dress up as hammer and discuss this. Diuretics as the main stay again?Then there is also the negative wording with regards to nitrates and NIV.

Haven't we been through this already?

Patients with AHF are symptomatic because of pulmonary and or systemic congestion and end organ dysfunction from decreased cardiac output.

Furosemide will reduce preload via diuresis, but most of these patients are already clinically dry. Besides the fact that you need to have a functioning kidney to ultrafiltrate out the fluid, loop diuretics have a long duration of action (i.e. 2hours and longer), it is not an easily titratable drug as compared to nitrates. It is hard to ignore the continuous fear of hypokalemia and its complications from high dose loop diuretics.

NIV with PEEP saves lives. The data is there. This should not even come up in 2014.

The acute management guidelines are as below (those in red are the contentious points and the emphasis is mine) :

1.3 Initial pharmacological treatment 

1.3.1  For guidance on patient consent and capacity follow recommendations 1.2.12 and 1.2.13 in Patient experience in adult NHS services (NICE clinical guideline 138).

1.3.2  Do not routinely offer opiates to people with acute heart failure.

1.3.3  Offer intravenous diuretic therapy to people with acute heart failure. Start treatment using either a bolus or infusion strategy.

1.3.4  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.

1.3.5  Closely monitor the person's renal function, weight and urine output during diuretic therapy.

1.3.6  Discuss with the person the best strategies of coping with an increased urine output.

1.3.7  Do not routinely offer nitrates to people with acute heart failure.

1.3.8  If intravenous nitrates are 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 in a setting where at least level 2 care[1] can be provided.

1.3.9  Do not offer sodium nitroprusside to people with acute heart failure.

1.3.10  Do not routinely offer inotropes or vasopressors to people with acute heart failure.

1.3.11  Consider inotropes or vasopressors in people with acute heart failure with potentially reversible cardiogenic shock. Administer these treatments in a cardiac care unit or high dependency unit or an alternative setting where at least level 2 care[1] can be provided.

1.4 Initial non-pharmacological treatment 

1.4.1  Do not routinely use non-invasive ventilation (continuous positive airways pressure [CPAP] or non-invasive positive pressure ventilation [NIPPV]) in people with acute heart failure and cardiogenic pulmonary oedema.

1.4.2  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.

1.4.3  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.

1.4.4  Do not routinely offer ultrafiltration to people with acute heart failure.

1.4.5  Consider ultrafiltration for people with confirmed diuretic resistance[2].

 

Additional articles worth reading: 

NIV is a saviour and prevents intubations in early decompensated patients. :

http://www.nejm.org/doi/full/10.1056/NEJMoa0707992

NIce Guidance :

Summarised : http://www.nice.org.uk/guidance/cg187/resources/guidance-acute-heart-failure-pdf

Full : http://www.nice.org.uk/guidance/cg187/evidence/cg187-acute-heart-failure-full-guideline3

Use of diuretics associated with increased mortality:

1. Diuretic usage in heart failure: a continuing conundrum - http://www.ncbi.nlm.nih.gov/pubmed/15734765

2.  Diuretic resistance predicts mortality in patients with advanced heart failure -

http://www.ncbi.nlm.nih.gov/pubmed/12094185