August 17th, 2011

Details of Updated U.K. Heart Failure Guidelines Raise Some Eyebrows

Although the updated heart failure guidelines from the U.K.’s National Institute for Health and Clinical Excellence (NICE) are broadly consistent with similar guidelines from Europe and the U.S., outside experts are questioning several key details of the update. A summary of the new guidelines has been published in the Annals of Internal Medicine, along with an editorial by Pamela Peterson and John Rumsfeld that is broadly supportive of the update, but calls into question several points.

Much of the controversy revolves around the relative weight given to echocardiography and natriuretic peptides in the diagnosis and treatment of heart failure. The updated NICE guidelines recommend that for the diagnosis of heart failure in patients with no history of MI, echocardiography should be used only if natriuretic peptides are raised. Peterson and Rumsfeld point out that both the ESC and ACC/AHA guidelines recommend that all patients with the signs and symptoms of heart failure should have an echocardiogram. The NICE position, they say, “may be questioned because of the utility of echocardiography for not only measuring left ventricular function but also for detecting structural or valvular heart disease, pulmonary hypertension, and pericardial effusion.”

The editorialists also take issue with the NICE assertion that serial natriuretic peptide monitoring is cost-effective only when performed by specialists and only when used in select heart failure patients. They write: “Some may argue that natriuretic peptide monitoring should be used more broadly.”

Finally, Peterson and Rumsfeld point out that because the updated NICE guidelines base their recommendations regarding ICDs on cost-effectiveness calculations as well as on clinical trial evidence, they therefore “differ from guidelines from other organizations that do not explicitly incorporate economic factors.”

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