The video version of this podcast can be found here:

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This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106], last updated in September 2025. Today’s episode focuses on the additional management of heart failure.

In previous episodes we covered the initial assessment and diagnosis and the drug management of the different subtypes of heart failure.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

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There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE guideline on Chronic heart failure in adults: diagnosis and management [NG106] can be found here:

·      https://www.nice.org.uk/guidance/ng106

Additional information on ARNIs can be found here:

·      https://www.ncbi.nlm.nih.gov/books/NBK507904/#:~:text=Mechanism%20of%20Action,-The%20pathophysiology%20of&text=Valsartan%20is%20an%20angiotensin%20receptor,neprilysin%20will%20accumulate%20angiotensin%20II

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to go through the NICE guideline on Chronic heart failure, which was last updated in September 2025.

Today’s episode focuses on the additional management of heart failure.

If you haven’t already, I recommend that you check the previous episodes where we covered heart failure diagnosis and the drug management of the different subtypes of heart failure.

Right, let’s jump into it.

And as we have just said, today we’re going to focus on the additional management of heart failure.

Now let’s start by looking at how to initiate and monitor medication use.

When tailoring treatment, we should use the person’s medical history, frailty status, and prognosis to decide which specific medicine combinations to use and how to introduce them.

In primary care, we should seek the advice from a heart failure specialist before starting someone on an angiotensin receptor–neprilysin inhibitor, that is, sacubitril/ valsartan.

Before prescribing an ACE inhibitor, ARB, angiotensin receptor-neprilysin inhibitor (ARNI), or mineralocorticoid receptor antagonist, we will measure renal function and electrolytes.

Once these drugs have been started, we should measure renal function and electrolytes:

• one to two weeks after starting treatment,
• one to two weeks after each dose increment,
• every three to six months once the maximum tolerated dose has been established,
• and at any time renal function may be compromised.

If the serum creatinine increases by more than 50%, or potassium rises above 5.5 millimoles per litre, we will follow local guidelines.

We will measure blood pressure, or ask the person to measure it themselves, before and after each dose increment. For people with symptoms of postural hypotension, we will measure blood pressure according to the NICE hypertension guideline, which essentially recommends ideally checking the initial blood pressure in the supine position, and then again after standing for at least 1 minute, in order to check for a drop in systolic blood pressure of 20 mmHg or more. Although checking the BP in a seated position can also be acceptable, we need to remember that measuring blood pressures from sitting to standing may miss some cases of postural hypotension, especially in older or frail people, and that measuring from lying to standing is more accurate for detecting a significant postural drop.

When prescribing beta-blockers, we should not withhold treatment solely because of age, or the presence of peripheral vascular disease, erectile dysfunction, diabetes, interstitial pulmonary disease, or COPD.

We will assess heart rhythm, heart rate, and conduction abnormalities using a 12-lead ECG before deciding whether to prescribe a beta-blocker.

We will not offer a beta-blocker to people with second-degree or third-degree heart block who do not have a pacemaker, or to those with bradycardia, that is, a heart rate below 50 beats per minute.

We will assess heart rate and clinical status after each betablocker dose increment, and for people with symptoms and bradycardia, we will consider repeating a 12-lead ECG after each dose increment.

For digoxin, we will not routinely monitor serum digoxin concentrations. But we should be aware that a digoxin level measured within 8 to 12 hours of the last dose may help confirm toxicity or non-adherence, but we must interpret results in the clinical context, since toxicity may occur even when the concentration is within the therapeutic range.

Now, let us move on to clinical review.

We will monitor all people with heart failure and provide:

·      a clinical general assessment including cardiac rhythm

·      a medication review checking for any necessary changes or side effects,

·      An assessment of renal function, and

·      Measurement of iron status and haemoglobin.

This is just the very minimum, Additionally, we should provide more detailed monitoring for people with significant comorbidities, co-prescribed medications, or recent deterioration. The frequency of monitoring will depend on the clinical situation and the stability of the patient’s condition.

If the clinical condition or medication has changed, we should monitor the patient more frequently — from days to every two weeks. For stable people with proven heart failure, we will monitor at least every six months.

For people under 75 years old with heart fai