Sharon Swain

Management of Chronic Heart Failure in Adults: Synopsis of the National Institute for Health and Clinical Excellence Guideline

DESCRIPTION The National Institute for Health and Clinical Excellence released its first clinical guideline on heart failure in 2003. This synopsis describes the update of that guideline, which was released in August 2010 and discusses the diagnosis, treatment, and monitoring of heart failure. METHODS Guideline developers considered clinical evidence, health economic analyses, clinical expert opinion, and patient views. Systematic literature searches were performed, and an original decision model assessed the cost-effectiveness of serial measurement of serum natriuretic peptide to monitor patients with chronic heart failure. RECOMMENDATIONS First, this guideline update describes the role of serum natriuretic peptide measurement, echocardiography, and specialist assessment in the diagnosis of heart failure. Second, it presents a pathway for pharmacologic treatment, rehabilitation, and pacing therapy (including implantable cardioverter-defibrillator and cardiac resynchronization therapy) for patients with heart failure and left ventricular systolic dysfunction and patients with heart failure and preserved ejection fraction. Finally, it explains the recommendation to monitor patients with heart failure by using serial measurement of serum natriuretic peptide.

Diagnosis and initial management of acute stroke and transient ischaemic attack: summary of NICE guidance

In England, stroke is estimated to cost the economy about £7bn (€8.8bn;

Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance

13.9bn) a year. This total comprises direct costs to the National Health Service of about £2.8bn, cost of informal care of £2.4bn, and cost because of lost productivity and disability of £1.8bn.1 In the United Kingdom, the national sentinel stroke audits2 3 have shown that over the past 10 years increasing numbers of patients are being treated in stroke units, evidence based practice is increasing, and reductions in mortality and length of hospital stay have decreased. One of the main aims of the guidance issued by the National Institute for Health and Clinical Excellence (NICE) is to ensure that the specialist treatment and expertise recommended are available to all patients in England and Wales. This article summarises key recommendations in the NICE guideline for the diagnosis and initial management of acute stroke and transient ischaemic attack.4 NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the guideline development group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Rapid symptom recognition and diagnosis #### Outside hospital For people with sudden onset of neurological symptoms, use a validated tool such as the face, arm, speech test (FAST)5 to screen for a diagnosis of stroke or transient ischaemic attack.[ Based on moderate quality cohort studies and on the opinion of the Guideline Development Group (GDG) ] #### In hospital For people who are admitted to an accident and emergency department with a suspected stroke or transient ischaemic attack, establish the diagnosis rapidly using a validated tool such as ROSIER (Recognition of Stroke in the Emergency Room).6 [ Based on moderate quality cohort studies and on the GDG’s opinion ] ### Brain imaging for suspected transient ischaemic attack For people who have had a suspected …

Multiple sclerosis: summary of NICE guidance.

Heart failure affects 900 000 people in the United Kingdom.1 Its prevalence is increasing owing to improved prognosis of ischaemic heart disease (the major cause of heart failure) and an ageing population.2 3 The two main types of heart failure are left ventricular systolic dysfunction and that associated with preserved left ventricular ejection fraction. Both types have a poor prognosis, although the introduction of effective treatments has led to a fall in mortality from heart failure caused by left ventricular systolic dysfunction (from 26% at six months in 1995 to 14% at six months in 2005).4 New evidence has emerged on diagnosis, treatment, rehabilitation, and monitoring of people with heart failure, and use of this evidence to guide diagnosis and management is likely to improve outcomes further and increase the cost effectiveness of services. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the diagnosis and management of chronic heart failure (which is a partial update of its 2003 guidelines5).6 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. The new recommendations are indicated in parentheses. Evidence levels for the recommendations are given in italic in square brackets. With the exception of the recommendations on drug treatment, all the recommendations apply to the diagnosis and management of heart failure with left ventricular systolic dysfunction and heart failure with preserved ejection fraction. ### Diagnosis

Cost-effectiveness analysis of serial measurement of circulating natriuretic peptide concentration in chronic heart failure

Multiple sclerosis (MS) is the most common cause of serious physical disability in working age adults and affects over 100 000 people in the United Kingdom.1 It causes a range of symptoms and disability and requires a broad multidisciplinary approach. A 2008 report, however, suggested delays and limited access to specialist services for affected people.2 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE).3 The guideline scope does not include disease modifying drugs as these have been covered in other NICE guidance. NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the guideline development group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italics in square brackets. ### Diagnosing multiple sclerosis View this table: McDonald criteria4 for diagnosis of multiple sclerosis

Management of lower urinary tract dysfunction in neurological disease: summary of NICE guidance

Objective To assess the cost-effectiveness of three monitoring strategies for optimising medical therapy in chronic heart failure (CHF). Design This analysis was based on six randomised controlled trials. Costs were measured from a UK NHS perspective and estimated for patients’ lifetime. The health outcome was the quality-adjusted life-year (QALY). Setting Hospital and community. Patients Patients with CHF. Interventions Serial measurement of natriuretic peptide (NP) by a specialist, clinical assessment by a specialist, and usual care in the community. Main outcome measures Costs, QALYs, and incremental cost-effectiveness ratio (ICER). Results Serial NP measurement by a specialist was the most cost-effective option in patients with CHF due to left ventricular systolic dysfunction (LVSD), showing an ICER of £3304 compared with clinical assessment. Serial NP measurement by a specialist was strongly favoured in patients with CHF from any cause, for all patients (ICER of £14 694 compared with clinical assessment by a specialist) and for the age subgroup ≤75 years (ICER of £2517 compared with usual care). However, serial NP measurement by a specialist was dominated (less effective and more costly) by alternative strategies in the subgroup age >75 years with CHF from any cause. Clinical assessment by a specialist of patients >75 years of age with CHF from any cause was cost-effective compared with usual care (ICER of £11 508). Conclusions Serial measurement of NP concentration by a specialist is the most cost-effective strategy for CHF due to LVSD and from any cause, except in the subgroup of patients >75 years with CHF from any cause, where treatment guided by NP measurement may be harmful and not cost-effective.

NICE guideline on acute stroke and TIA: commentary

A wide range of neurological conditions can affect the function of the lower urinary tract, potentially causing distressing symptoms and even renal damage. It is important to ask patients with neurological disease about urinary symptoms, as identifying these should lead to appropriate assessment and treatment, improvement in quality of life, and a reduction in long term morbidity. Clinicians can easily overlook urinary tract problems as they focus on other important clinical matters, but a better understanding of how to deal with lower urinary tract problems may increase the confidence of healthcare professionals in this area. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of lower urinary tract dysfunction in neurological disease.1 NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Initial assessment Patients needing assessment include those with newly diagnosed neurological disease; those with known neurological disease and new or changing symptoms suggesting urinary tract dysfunction; and those requiring periodic reassessment of their urinary tract management. The interval between routine assessments will depend on the person (for example, their age or diagnosis) but should not exceed three years.

Issues and challenges for research in major trauma

The National Stroke Strategy,1 published in 2007, outlined a “National Ambition for Stroke” where every patient with stroke or transient ischaemic attack (TIA) receives timely and evidence-based stroke care from the moment of symptom onset. The recent publication of the NICE guideline on diagnosis and initial management of acute stroke and TIA2 provides clinicians, service providers and commissioners with the evidence to support acute and hyperacute care following a neurovascular episode. The challenge is now to implement the evidence in every acute and primary care trust across the country. Stroke clinicians are working alongside their cardiological colleagues now in managed clinical “cardiac and stroke” networks to develop systems of care that will implement the new evidence so that every patient, wherever and whenever they present, can have equal access to high-quality services. The guideline emphasises the importance of early recognition of stroke symptoms, and recommends a validated diagnostic tool such as Face Arm and Speech Test (FAST). This will require a community awareness programme involving the public and front-line healthcare workers. The Stroke Association and Department of Health launched a national awareness programme in the spring of 2009 to develop awareness of FAST and encourage patients to seek urgent paramedic attention. Paramedics need to have clear protocols for the management of “FAST-positive” patients, and clinical networks have a vital role to play in ensuring that the right services are available in the right place and at the right time. This may involve transporting patients to designated “stroke centres” rather than to a local district hospital, if this means more ready availability of urgent assessment and treatment. A number of different stroke centre models are being developed across the country, depending on local geography …

Diagnosis and clinical management of alcohol related physical complications: summary of NICE guidance

The starting point for evidence-based guidelines is the systematic review and critical appraisal of the relevant literature. This review highlights the risk of bias identified while critically appraising the evidence to inform the National Institute of Health and Care Excellence guideline on the assessment and initial management of major trauma.

Assessment and management of alcohol dependence and withdrawal in the acute hospital: concise guidance.

Continued hazardous and harmful drinking can result in dependence and tolerance, with risk of alcohol withdrawal syndrome on abrupt reduction or cessation; it may also result in damage to almost any organ or system in the body. Hazardous and harmful drinkers are commonly encountered among hospital patients, with 863 300 alcohol related admissions to hospital in 2007-8, an increase of 69% since 2002-3.1 The cost to the NHS of treating acute and chronic drinking is estimated to be as much as £2.7bn a year.2 This article summarises recommendations made in the recent guidance from the National Institute for Health and Clinical Excellence (NICE) for the diagnosis and clinical management of alcohol related physical complications in adults and children (aged over 10 years).3 That guideline should be read in conjunction with the NICE public health guidance on the prevention and early identification of alcohol use disorders in adults and young people4 and the forthcoming NICE clinical guideline on the management of alcohol dependence and harmful alcohol use.5 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Acute alcohol withdrawal #### Admission to hospital