Clinical Question

How should new onset acute heart failure be identified and treated?

Bottom Line

There is not much new in these guidelines except some caveats on what not to do. Diagnose new acute heart failure with a natriuretic peptide measurement and, if the level is high, follow with transthoracic echocardiography. Do not routinely treat with opiates, nitrates, inotropes, vasopressors, or continuous positive airway pressure ventilation. Almost all of their recommendations are based on very low quality evidence, often from nonrandomized studies. It is not that their recommendations are suspect; it is more of a comment on the state of the evidence for treatment of a very common problem. (Level of Evidence = 5)

Synopsis

These guidelines come from the United Kingdom's National Institute for Health and Care Excellence (NICE). They suggest a two-step method of diagnosing suspected acute heart failure: Perform a single measurement of either serum natriuretic peptides and, if greater than 100 pg per mL (100 ng per L) for B-type natriuretic peptide or 300 pg per mL (300 ng per L) for N-terminal pro-B-type natriuretic peptide, follow with transthoracic echocardiography within 48 hours. Treat with a diuretic and a beta blocker, and consider starting an angiotensin-converting enzyme inhibitor (or angiotensin receptor blocker if the patient experiences intolerable adverse effects) in patients with reduced ejection fraction. Consider an aldosterone antagonist only in patients who cannot tolerate either of these approaches. The guidelines specifically recommend against several treatment approaches: routine use of opiate, nitrate, inotrope, or vasopressor therapy, and routine noninvasive ventilation (e.g., continuous positive airway pressure ventilation).

Study design: Practice guideline

Funding source: Government

Setting: Various (guideline)

Reference: DworzynskiKRobertsELudmanAMantJGuideline Development GroupDiagnosing and managing acute heart failure in adults: summary of NICE guidance. BMJ.2014; 349: g5695.