The Pharmaceutical Journal
Vol 271 No 7259 p107
26 July 2003

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Start with ACE inhibitor then add beta blocker in heart failure, says NICE

Angiotensin converting enzyme (ACE) inhibitors should be considered first line treatment for all patients diagnosed with heart failure caused by left ventricular systolic dysfunction, the National Institute for Clinical Excellence says.

Diuretic therapy should be routinely used to relieve congestive symptoms. Then, regardless of whether symptoms persist or not, a beta blocker licensed for use in heart failure — currently carvedilol (Eucardic) or bisoprolol — should be initiated.

These recommendations are made in NICE's latest clinical guideline, its fifth, published earlier this week.

Dr Mike Pearson, director of the National Collaborating Centre for Chronic Conditions, which developed the guideline on behalf of NICE, said: "The guideline challenges some previously accepted habits, recommending, for example, using ACE inhibitor drugs as the first line — in the expectation that this will prolong life for many."

At the launch of the guideline, Professor Martin Cowie, National Heart and Lung Institute, Imperial College, London, explained that the guideline was an extension of the National Service Framework for Coronary Heart Disease. "The guideline is more specific about the use of drugs to manage heart failure. It doesn't contradict the NSF in any way." Professor Cowie also highlighted the value of a multidisciplinary approach to the care of patients with heart failure. Dr Pearson added that although the guideline sets out what needs to be done, it does not stipulate which health professional should be doing it. Dr Roger Boyle, national director for heart disease, Department of Health, echoed this view saying that a whole range of staff, including pharmacists, could be involved. "It's more about what is done rather than who does it," he said.

The guideline gives specific recommendations about which ACE inhibitor and beta blocker to use and at what dose. It also sets out when other drugs should be introduced.

In addition, the guideline makes recommendations for heart failure diagnosis and monitoring of patients. It stipulates that all patients should be monitored and that this should include a review of medication, looking at the need for changes and possible side effects.

Patients with heart failure should be offered annual vaccination against influenza and should be encouraged to make lifestyle changes, such as stopping smoking.

The guideline is available via the NICE website. A full version can be purchased from the Royal College of Physicians (tel 020 7935 1174, e-mail publications@rcplondon.ac.uk), price £25.