These recommendations are based on guidance issued by the National Institute for Health and Clinical Excellence (NICE) [National Clinical Guideline Centre for Acute and Chronic Conditions, 2010] and expert opinion [Sanderson, 2007; European Society of Cardiology, 2008; Heart Failure Society of America, 2010].

Diuretics

• Indirect evidence from two small clinical trials suggests that diuretics may improve symptoms in people with heart failure with preserved ejection fraction (HFPEF).

Other drug treatments

• NICE recommends obtaining specialist advice about additional drug treatments for people with HFPEF, as there is considerable uncertainty about optimal drug treatments for HFPEF.
• Evidence from one trial suggests that there is modest clinical benefits of candesartan as add-on treatment in people with HFPEF. Evidence from another four trials found no benefit or modest clinical benefits from adding angiotensin-converting enzyme (ACE) inhibitors or angiotensin-II receptor antagonists (AIIRAs) to other treatments for HFPEF.
• There is evidence from one small study that propranolol may reduce the risk of death in older people with HFPEF and history of myocardial infarction.
• NICE reviewed the evidence on ACE inhibitors and AIIRAs and beta-blockers for treating people with HFPEF and concluded that evidence is insufficient to support their use [National Clinical Guideline Centre for Acute and Chronic Conditions, 2010].
• ACE inhibitors (or AIIRAs) and beta-blockers may be indicated to treat underlying causes and comorbidities of heart failure.

Specialist

• NICE defines the term 'specialist' as a physician with sub-speciality interest in heart failure (often a consultant cardiologist) who leads a specialist multidisciplinary heart failure team of professionals with appropriate competencies from primary and secondary care. The team will involve, where necessary, other services (such as rehabilitation, tertiary care, and palliative care) in the care of individual persons.

These recommendations reflect the National Institute for Health and Clinical Excellence (NICE) guideline Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care [National Clinical Guideline Centre for Acute and Chronic Conditions, 2010] and are in line with international guidelines [ICSI, 2007; SIGN, 2007; European Society of Cardiology, 2008].

Functional capacity

• The New York Heart Association (NYHA) classification of functional capacity has been widely used over many decades, both in research and clinical practice. The current version is the result of a series of updates to the 1928 classification [American Heart Association, 1994]. It aims to provide a standard and more objective way of describing severity of symptoms.
• A UK survey of 30 cardiologists found that they had no consistent method for assessing NYHA class [Raphael et al, 2006]. The same report included a study of inter-operator variability among four cardiologists assessing 50 people. The average concordance between any pair of cardiologists was 54%, and there was very poor agreement in differentiating between class II and class III. The authors considered the NYHA classification to be useful despite these limitations and recommended that the objectivity of the classification be improved by clarifying how 'ordinary physical activity', 'slight limitation', and 'marked limitation' are elicited from people.

Fluid status

• Fluid status should be determined because this allows response to treatment to be assessed and guides further management.

Assessing cardiac rhythm

• It is important to regularly and routinely assess cardiac rhythm because people with heart failure frequently have treatable arrhythmias (especially atrial fibrillation), and these can be discovered at any time before, at, or after the initial presentation with heart failure.
• If the person's symptoms deteriorate and their pulse is regular, electrocardiography should be considered because atrial tachycardia can be regular and may be missed on clinical examination.
• For more information, see Complications.

These recommendations reflect recommendations in the National Institute for Health and Clinical Excellence (NICE) guideline Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care [National Clinical Guideline Centre for Acute and Chronic Conditions, 2010], as well as guidelines from the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2007] and European Society of Cardiology guidelines [European Society of Cardiology, 2008].

Recognizing the symptoms of heart failure

• The recommendation to teach people how to recognize the symptoms of heart failure is largely based on expert opinion [European Society of Cardiology, 2008].

How to monitor body weight

• The recommendation to teach people to monitor their weight is largely based on expert opinion [SIGN, 2007; European Society of Cardiology, 2008].
• Evidence from one study indicates that increases in body weight are not always associated with a deterioration of symptoms of heart failure and fluid retention [Lewin et al, 2005].

Keeping active and fit

• Keeping active and fit is generally recommended — see the CKS topic on CVD risk assessment and management. This may be even more important for people with heart failure and is widely recommended by experts on the basis of experience and evidence of benefit that is not always consistent [ICSI, 2007; SIGN, 2007; European Society of Cardiology, 2008; National Clinical Guideline Centre for Acute and Chronic Conditions, 2010].
• Older systematic reviews found small studies providing evidence that exercise reduces mortality and hospitalization, and improves exercise tolerance and health-related quality of life [Piepoli et al, 2004; Rees et al, 2004; Smart and Marwick, 2004].
• Two more recent randomized controlled trials (RCTs) in people with chronic heart failure suggest that intensive aerobic exercise may be more effective than less intensive exercise and weight training [Feiereisen et al, 2007; Wisloff et al, 2007].
• A small RCT found that 6 years after participation in a residential rehabilitation programme, people with chronic heart failure had slightly better outcomes than the control group, maintained exercise capacity, and engaged in activities that exceed the minimal amount recommended by guidelines for cardiovascular health [Mueller et al, 2007].
• A large RCT (1159 participants) found that exercise training resulted in a nonsignificant reduction in the risk of death (from any cause) or hospitalization, and a small but statistically significant improvement in self-reported health status [Flynn et al, 2009; O'Connor et al, 2009].
• A systematic review on the effects of moderate- to high-intensity resistance training in people with chronic heart failure found 10 trials, all with methodological flaws [Spruit et al, 2009]. The review concluded that the evidence on benefits was weak and inconsistent and that there was no evidence of harm.

Stopping smoking

• Stopping smoking is recommended for everyone — see the CKS topic on Smoking cessation. It may be even more important for people with heart failure.
• The effect of smoking cessation in people with heart failure has not been studied in clinical trials. However, current smoking was an independent predictor of readmissions for heart failure in two observational studies [Evangelista et al, 2000; Suskin et al, 2001].

Prudent use of alcohol

• Prudent use of alcohol is generally recommended — see the CKS topic on Alcohol - problem drinking. It may be even more important for people with heart failure.
• A recent review [Djousse and Gaziano, 2008] found:
• Good evidence that heavy alcohol use is associated with cardiomyopathy and that abstinence leads to improved survival.
• Limited evidence that moderate alcohol use reduces the risk of heart failure compared with abstinence.
• No evidence on the type of beverage and heart failure, or on drinking patterns (binge drinking versus frequent light to moderate drinking) and heart failure.

Losing excess weight and maintaining weight loss

• Losing excess weight and maintaining weight loss are generally recommended — see the CKS topic on Obesity.
• Losing excess weight is thought to be important for people with heart failure, although there is little evidence to support this assumption [Kenchaiah et al, 2007; Abdulla et al, 2008; Shirley et al, 2008].

Restricting salt consumption

• The recommendation to restrict salt consumption is largely based on expert opinion and extrapolation from evidence of the effects of salt consumption on hypertension [SIGN, 2007; European Society of Cardiology, 2008].
• Two RCTs of low-salt diets in people with heart failure found weak evidence for modest benefits in terms of weight loss, oedema, fatigue, quality of life, and New York Heart Association classification of heart failure [Alvelos et al, 2004; Colin Ramirez et al, 2004].

Restricting fluid intake

• The recommendation to restrict fluid intake in people with severe symptoms of heart failure is largely based on expert opinion [SIGN, 2007; European Society of Cardiology, 2008].
• One open-label RCT in people hospitalized for severe heart failure symptoms failed to find evidence of benefit from fluid restriction [Travers et al, 2007]. Nevertheless, there is no concern that fluid restriction to 1.5–2 L per day could be harmful.

Diarrhoea and vomiting

• The recommendation to stop treatment with an ACE inhibitor, AIIRA, diuretic, or spironolactone for a short time (1–2 days) is based on concern that continued treatment may increase the risk of acute renal failure [Stirling et al, 2003; McGuigan et al, 2005], and CKS expert reviewers (based on pharmacological and physiological knowledge of drug effects on the kidney).

Immunizations

• The recommendation for influenza and pneumococcal immunization is largely based on expert opinion and extrapolation from the benefits of these immunizations in other populations at risk — see the CKS topics on Immunizations - seasonal influenza and Immunizations - pneumococcal.
• A large epidemiological study in elderly people found that immunization against influenza was associated with reductions in the risk of hospitalization for heart disease, cerebrovascular disease, and pneumonia or influenza, as well as the risk of death from all causes during influenza seasons [Nichol et al, 2003].

• This information is from the Driver and Vehicle Licensing Agency [DVLA, 2010].

These recommendations and information are in line with recommendations in the National Institute for Health and Clinical Excellence (NICE) guideline Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care [National Clinical Guideline Centre for Acute and Chronic Conditions, 2010], as well as European professional association guidelines [European Society of Cardiology, 2008].

Risk of sexual activity

• The recommendation to counsel people about sexual activity and the advice on the safety of sexual activity are largely based on expert opinion [European Society of Cardiology, 2008] and a consensus development panel [Jackson et al, 2006].

Interaction between nitrates/nicorandil and phosphodiesterase inhibitors

• The combination of a phosphodiesterase inhibitor and a nitrate (including amyl nitrite) or nicorandil can result in excessive hypotension and possibly precipitate myocardial infarction [Baxter, 2010].
• The interaction with phosphodiesterase inhibitors is well established and clinically significant.
• It is not yet established whether nicorandil interacts with phosphodiesterase inhibitors to the same extent, but the manufacturers recommend that its use is contraindicated with phosphodiesterase inhibitors.

• These recommendations are based on published expert opinion from the Working Group of the British Cardiovascular Society, Fitness to fly for passengers with cardiovascular disease [Smith et al, 2010].
• Commercial airline passengers breathe air with a reduced oxygen content that results in low blood oxygen saturations, which may be expected to have adverse effects on people with heart failure. There is little evidence regarding the effects of hypoxia in people with heart failure. The Working Group of the British Cardiovascular Society found evidence from three small trials that [Smith et al, 2010]:
• In people with stable heart failure, including New York Heart Association (NYHA) class III or IV, short-term (up to 1 hour) hypoxia at rest produces no significant adverse effects.
• People with mild to moderate stable heart failure (NYHA class II) can tolerate up to 7 hours of hypoxia at rest.
• The Working Group of the British Cardiovascular Society did not find evidence that in-flight oxygen prevents adverse effects in people with heart failure. However, the Working Group recommended that access to in-flight oxygen should be available for passengers who have severe heart failure (NYHA class IV). They also state that availability of in-flight oxygen should be considered for people with NYHA class III.

• This information is in line with recommendations in the National Institute for Health and Clinical Excellence (NICE) guideline Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care [National Clinical Guideline Centre for Acute and Chronic Conditions, 2010], as well as Scottish national guidelines and European professional association guidelines [SIGN, 2007; European Society of Cardiology, 2008]. These guidelines strongly emphasize the importance of providing information to affected individuals, their family, and carers.

The recommendations for referral reflect the National Institute for Health and Clinical Excellence (NICE) guideline Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care [National Clinical Guideline Centre for Acute and Chronic Conditions, 2010] and are largely based on expert opinion.

Specialist

• NICE defines the term 'specialist' as a physician with sub-speciality interest in heart failure (often a consultant cardiologist) who leads a specialist multidisciplinary heart failure team of professionals with appropriate competencies from primary and secondary care. The team will involve, where necessary, other services (such as rehabilitation, tertiary care, and palliative care) in the care of individual persons.