Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Diagnosis and Investigations
B - Brain natriuretic peptide (BNP) or N terminal-pro-BNP (NT pro-BNP) levels and/or an electrocardiogram should be recorded to indicate the need for echocardiography in patients with suspected heart failure.
B - A chest X-ray is recommended early in the diagnostic pathway to look for supportive evidence of chronic heart failure and to investigate other potential causes of breathlessness.
C - All patients with heart failure should be advised to refrain from excessive alcohol consumption. When the aetiology of heart failure is alcohol related, patients should be strongly encouraged to stop drinking alcohol.
B - Patients with chronic heart failure should be strongly advised not to smoke and should be offered smoking cessation advice and support.
B - Motivational techniques should be used to promote regular low intensity physical activity amongst patients with stable heart failure.
A - Angiotensin converting enzyme inhibitors should be considered in patients with all New York Heart Association (NYHA) functional classes of heart failure due to left ventricular systolic dysfunction.
A - All patients with heart failure due to left ventricular systolic dysfunction of all NYHA functional classes should be started on beta-blocker therapy as soon as their condition is stable (unless contraindicated by a history of asthma, heart block or symptomatic hypotension).
A - Patients with chronic heart failure due to left ventricular systolic dysfunction alone, or heart failure, left ventricular systolic dysfunction or both following myocardial infarction who are intolerant of angiotensin converting enzyme inhibitors should be considered for an angiotensin receptor blocker.
B - Patients with heart failure due to left ventricular systolic dysfunction who are still symptomatic despite therapy with an angiotensin converting enzyme inhibitor and a beta-blocker may benefit from the addition of candesartan, following specialist advice.
B - Following specialist advice, patients with moderate to severe heart failure due to left ventricular systolic dysfunction should be considered for spironolactone unless contraindicated by the presence of renal impairment or a high potassium concentration.
B - Patients who have suffered a myocardial infarction and with left ventricular ejection fraction <40% and either diabetes or clinical signs of heart failure should be considered for eplerenone unless contraindicated by the presence of renal impairment or a high potassium concentration.
B - Diuretic therapy should be considered for heart failure patients with dyspnoea or oedema (ankle or pulmonary).
A - Digoxin should be considered as an add-on therapy for heart failure patients in sinus rhythm who are still symptomatic after optimum therapy.
A - African American patients with advanced heart failure due to left ventricular systolic dysfunction should be considered for treatment with hydralazine and isosorbide dinitrate in addition to standard therapy.
B - Patients who are intolerant of an angiotensin converting enzyme inhibitor and an angiotensin II receptor blocker due to renal dysfunction or hyperkalaemia should be considered for treatment with a combination of hydralazine and isosorbide dinitrate.
D - Patients with chronic heart failure should receive one pneumococcal vaccination and an annual influenza vaccination.
Patients with Left Ventricular Systolic Dysfunction
A - For patients in sinus rhythm with drug refractory symptoms of heart failure due to left ventricular systolic dysfunction (left ventricular ejection fraction <35%) and who are in NYHA class III or IV and who have a QRS duration of >120 ms, cardiac resynchronisation should be considered.
B - Patients with obstructive sleep apnoea and heart failure may be safely treated with continuous positive airway pressure.
B - Consideration should be given to enrolling stable heart failure patients who are in NYHA class II – III into a moderate intensity supervised exercise training programme to give improved exercise tolerance and quality of life.
Surgical Assessment and Intervention
B - In patients undergoing coronary artery bypass grafting with left ventricular ejection fraction <35% consideration should be given to preoperative introduction of intraaortic balloon counterpulsation.
Models of Care
A - Comprehensive discharge planning should ensure that links with post-discharge services are in place for all those with symptomatic heart failure. A nurse led, home based element should be included.
A - Follow up (including by telephone) by trained heart failure nurses should be considered for patients post-discharge or with stable heart failure. Nurses should have the ability to alter diuretic dose and the interval between telephone calls, and recommend emergency medical contact.
A - Patients with heart failure should be offered multidisciplinary follow up, including pharmacy input to address knowledge of drugs and compliance. Follow up should include feedback to clinicians about possibilities for optimising pharmacological interventions.
Refer to the original guideline document for a discussion of palliative care for patients with chronic heart failure.
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g. case reports, case series)
4: Expert opinion