Context
Key facts and figures
Heart failure is a complex clinical syndrome of symptoms and signs caused by impaired heart function. When this affects mainly the left ventricle, it can be due to either weakness of contraction or impaired relaxation of the left ventricle. Other problems affecting the right ventricle, the heart valves, the pulmonary circulation or the pericardium can lead to the development of heart failure.
Almost 1 million people in the UK are currently diagnosed with heart failure, with 200,000 new cases each year. Both the incidence and prevalence of heart failure increase steeply with age. The average age at diagnosis is 76 years. Increases in life expectancy, including for people with ischaemic heart disease and hypertension, has increased the incidence of heart failure. The increased prevalence of obesity is another contributor to the rising incidence and prevalence of heart failure.
Current practice
NICE's 2018 guideline on chronic heart failure concentrated on the weak left ventricular contraction phenotype of heart failure, otherwise called heart failure with reduced ejection fraction, as it was then the only phenotype of chronic heart failure where we had evidence-based treatments. The treatment algorithm then was based on stepwise introduction of medicines aiming to provide people with at least angiotensin-converting enzyme (ACE) inhibitors, beta-blockers and, if remaining symptomatic, mineralocorticoid receptor antagonists (MRAs). Those who continued to be symptomatic would be considered by the specialist heart failure multidisciplinary team for 1 or more of 4 further medicines.
Since 2018, we have seen new developments in the treatment of not only heart failure with reduced ejection fraction, but also new evidence emerged for the treatment of the people with heart failure due to stiff ventricle, called heart failure with preserved ejection fraction; in addition to some evidence for treating those with heart failure with mildly reduced ejection fraction.
In people with heart failure with reduced ejection fraction there will be a need to change the ethos of stepwise introduction of medicines and allow early initiation of multiple medicines before optimising the doses of each. The reason for the different approach being the evidence for impact on people's symptoms and prognosis at an early stage of introduction of each medicine class, and the tendency of all classes of medicine to lower blood pressure which, when exaggerated by optimising the dose of some of the medicines, can render the person unable to receive further treatment with other medicines.