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## Complete Summary

#### GUIDELINE TITLE

Management of chronic heart failure. A national clinical guideline.

#### BIBLIOGRAPHIC SOURCE(S)

Scottish Intercollegiate Guidelines Network (SIGN). Management of
chronic heart failure. A national clinical guideline. Edinburgh
(Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2007
Feb. 53 p. (SIGN publication; no. 95). \[155 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Diagnosis and treatment of
heart failure due to left ventricular systolic dysfunction. Edinburgh
(Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 1999. 68
p. (SIGN publication; no. 35).

This guideline was issued in 2007 and will be considered for review in
three years. Any updates to the guideline in the interim period will be
noted on the [Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/new.html).

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Chronic heart failure

#### GUIDELINE CATEGORY

Counseling\
Diagnosis\
Evaluation\
Management\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine\
Nursing\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To present evidence-based recommendations for diagnostic testing,
lifestyle modification, optimum pharmacological and interventional
treatments, organisation of care and discharge planning, and palliative
care of patients with chronic heart failure

#### TARGET POPULATION

Adult patients with chronic heart failure

#### INTERVENTIONS AND PRACTICES CONSIDERED

**[Diagnosis]{.underline}**

1.  Measurement of brain natriuretic peptide (BNP) or N terminal-pro-BNP
    (NT pro-PNP) levels and/or electrocardiogram

2.  Chest x-ray

3.  Clinical examination including full blood count, fasting blood
    glucose, serum urea and electrolytes, urinalysis, thyroid function

**[Treatment/Management]{.underline}**

**Behavioural Modification**

1.  Advice to refrain from excessive alcohol consumption or to stop
    drinking alcohol

2.  Smoking cessation advice and support

3.  Motivational techniques to promote regular low intensity physical
    activity

**Pharmacological Therapies**

1.  Angiotensin converting enzyme inhibitors

2.  Beta-blockers

3.  Angiotensin receptor blockers

4.  Candesartan, following specialist advice

5.  Spironolactone, following specialist advice

6.  Eplerenone

7.  Diuretic therapy

8.  Digoxin

9.  Hydralazine and isosorbide dinitrate

10. Pneumococcal vaccination and annual influenza vaccination

**Interventional Procedures**

*Patients with Left Ventricular Systolic Dysfunction*

1.  Cardiac resynchronisation

2.  Continuous positive airway pressure for obstructive sleep apnoea

3.  Moderate intensity supervised exercise training programmes

*Surgical Assessment and Intervention*

Intra-aortic balloon counterpulsation

**Models of Care**

1.  Comprehensive discharge planning

2.  Follow up by trained heart failure nurses

3.  Multidisciplinary follow up, including pharmacy input

#### MAJOR OUTCOMES CONSIDERED

**Diagnosis**

Sensitivity, specificity, and clinical effectiveness of diagnostic tools

**Treatment**

-   Left ventricular function

-   Cardiothoracic ratio on chest X-ray

-   Level of cardiac function

-   Morbidity and mortality

-   Hospitalisation rates

-   Exercise capacity

-   New York Heart Association (NYHA) class

-   Quality of life

-   Progression of disease

-   Level of symptoms

-   Patient compliance with therapy

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence base for this guideline was synthesised in accordance with
Scottish Intercollegiate Guidelines Network (SIGN) methodology. A
systematic review of the literature was carried out using an explicit
search strategy devised by a SIGN Information Officer. Searches were
focused on existing guidelines, systematic reviews, randomised
controlled trials, and (where appropriate) observational and/or
diagnostic studies. Databases searched include AMED, Medline, Embase,
Cinahl, PsychINFO, and the Cochrane Library. The year range covered was
1996-2005, though where questions overlapped with those addressed in the
2003 NICE guidelines on chronic heart failure searches were limited to
an update of the evidence tables from that guideline. The palliative
care literature was reviewed back to 1986. Internet searches were
carried out on various websites including those for the Guidelines
International Network, National Institute for Health and Clinical
Excellence, the National Library for Health, and the US National
Guidelines Clearinghouse. The Medline version of the main search
strategies can be found on the SIGN website, in the section covering
supplementary guideline material. The main searches were supplemented by
material identified by individual members of the development group. Each
of the selected papers was evaluated by two members of the group using
standard SIGN methodological checklists before conclusions were
considered as evidence.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**1++**: High quality meta-analyses, systematic reviews of randomised
controlled trials (RCTs), or RCTs with a very low risk of bias

**1+**: Well-conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias

**1-**: Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++**: High quality systematic reviews of case control or cohort
studies\
High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**: Well-conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**: Case control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not causal

**3**: Non-analytic studies (e.g. case reports, case series)

**4**: Expert opinion

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Once papers have been selected as potential sources of evidence, the
methodology used in each study is assessed to ensure its validity. The
result of this assessment will affect the level of evidence allocated to
the paper, which will in turn influence the grade of recommendation that
it supports.

The methodological assessment is based on a number of key questions that
focus on those aspects of the study design that research has shown to
have a significant influence on the validity of the results reported and
conclusions drawn. These key questions differ between study types, and a
range of checklists is used to bring a degree of consistency to the
assessment process. Scottish Intercollegiate Guidelines Network (SIGN)
has based its assessments on the MERGE (Method for Evaluating Research
and Guideline Evidence) checklists developed by the New South Wales
Department of Health, which have been subjected to wide consultation and
evaluation. These checklists were subjected to detailed evaluation and
adaptation to meet SIGN\'s requirements for a balance between
methodological rigour and practicality of use.

The assessment process inevitably involves a degree of subjective
judgment. The extent to which a study meets a particular criterion -
e.g., an acceptable level of loss to follow up and, more importantly,
the likely impact of this on the reported results from the study will
depend on the clinical context. To minimise any potential bias resulting
from this, each study must be evaluated independently by at least two
group members. Any differences in assessment should then be discussed by
the full group. Where differences cannot be resolved, an independent
reviewer or an experienced member of SIGN Executive staff will arbitrate
to reach an agreed quality assessment.

**Evidence Tables**

Evidence tables are compiled by SIGN executive staff based on the
quality assessments of individual studies provided by guideline
development group members. The tables summarise all the validated
studies identified from the systematic literature review relating to
each key question. They are presented in a standard format to make it
easier to compare results across studies, and will present separately
the evidence for each outcome measure used in the published studies.
These evidence tables form an essential part of the guideline
development record and ensure that the basis of the guideline
development group\'s recommendations is transparent.

Additional details can be found in the companion document titled \"SIGN
50: A Guideline Developers\' Handbook\" (see \"Availability of Companion
Documents\" field in this summary).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

**Synthesising the Evidence**

Guideline recommendations are graded to differentiate between those
based on strong evidence and those based on weak evidence. This judgment
is made on the basis of an (objective) assessment of the design and
quality of each study and a (perhaps more subjective) judgment on the
consistency, clinical relevance and external validity of the whole body
of evidence. The aim is to produce a recommendation that is
evidence-based, but which is relevant to the way in which health care is
delivered in Scotland and is therefore implementable.

It is important to emphasise that the grading does not relate to the
importance of the recommendation, but to the strength of the supporting
evidence and, in particular, to the predictive power of the study
designs from which that data was obtained. Thus, the grading assigned to
a recommendation indicates to users the likelihood that, if that
recommendation is implemented, the predicted outcome will be achieved.

**Considered Judgment**

It is rare for the evidence to show clearly and unambiguously what
course of action should be recommended for any given question.
Consequently, it is not always clear to those who were not involved in
the decision making process how guideline developers were able to arrive
at their recommendations, given the evidence they had to base them on.
In order to address this problem, SIGN has introduced the concept of
considered judgment.

Under the heading of considered judgment, guideline development groups
summarise their view of the total body of evidence covered by each
evidence table. This summary view is expected to cover the following
aspects:

-   Quantity, quality, and consistency of evidence

-   Generalisability of study findings

-   Directness of application to the target population for the guideline

-   Clinical impact (i.e., the extent of the impact on the target
    patient population, and the resources needed to treat them)

-   Implementability (i.e., how practical it would be for the NHS in
    Scotland to implement the recommendation)

Guideline development groups are provided with a pro forma in which to
record the main points from their considered judgment. Once they have
considered these issues, the group is asked to summarise their view of
the evidence and assign a level of evidence to it, before going on to
derive a graded recommendation.

Additional detail about SIGN\'s process for formulating guideline
recommendations is provided in Section 6 of the companion document
titled \"SIGN 50: A Guideline Developers\' Handbook\" (see
\"Availability of Companion Documents\" field).

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendation**

*Note: The grade of recommendation relates to the strength of the
evidence on which the recommendation is based. It does not reflect the
clinical importance of the recommendation.*

**A**: At least one meta-analysis, systematic review of randomized
controlled trials (RCTs), or RCT rated as 1++ and directly applicable to
the target population; *or*

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**: A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C**: A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 2++

**D**: Evidence level 3 or 4; *or*

Extrapolated evidence from studies rated as 2+

**Good Practice Points**: Recommended best practice based on the
clinical experience of the guideline development group

#### COST ANALYSIS

None of the trials related to post-discharge care conducted formal cost
effectiveness analyses but many did record the medical costs of each
comparator. Three meta-analyses consistently reported that implementing
a discharge-management plan reduced costs compared to usual care. The
resultant savings exceeded the cost of implementation by an average of
over six times (range two to 14 times). The savings arose primarily from
the lower rate of re-admissions. The only study where the intervention
costs exceeded savings provided follow up support in a day hospital.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The national open meeting is the main consultative phase of Scottish
Intercollegiate Guidelines Network (SIGN) guideline development.

**Peer Review**

All SIGN guidelines are reviewed in draft form by independent expert
referees, who are asked to comment primarily on the comprehensiveness
and accuracy of interpretation of the evidence base supporting the
recommendations in the guideline. A number of general practitioners
(GPs) and other primary care practitioners also provide comments on the
guideline from the primary care perspective, concentrating particularly
on the clarity of the recommendations and their assessment of the
usefulness of the guideline as a working tool for the primary care team.
The draft is also sent to a lay reviewer in order to obtain comments
from the patient\'s perspective. The comments received from peer
reviewers and others are carefully tabulated and discussed with the
chairman and with the guideline development group. Each point must be
addressed and any changes to the guideline as a result noted or, if no
change is made, the reasons for this recorded.

As a final quality control check prior to publication, the guideline and
the summary of peer reviewers\' comments are reviewed by the SIGN
Editorial Group for that guideline to ensure that each point has been
addressed adequately and that any risk of bias in the guideline
development process as a whole has been minimised. Each member of the
guideline development group is then asked formally to approve the final
guideline for publication.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

***Note from the Scottish Intercollegiate Guidelines Network (SIGN) and
National Guideline Clearinghouse (NGC)**: In addition to these
evidence-based recommendations, the guideline development group also
identifies points of best clinical practice in the full-text guideline
document.*

The grades of recommendations (A--D) and levels of evidence (1++, 1+,
1-, 2++, 2+, 2-, 3, 4) are defined at the end of the \"Major
Recommendations\" field.

**[Diagnosis and Investigations]{.underline}**

**B** - Brain natriuretic peptide (BNP) or N terminal-pro-BNP (NT
pro-BNP) levels and/or an electrocardiogram should be recorded to
indicate the need for echocardiography in patients with suspected heart
failure.

**B** - A chest X-ray is recommended early in the diagnostic pathway to
look for supportive evidence of chronic heart failure and to investigate
other potential causes of breathlessness.

**[Behavioural Modifications]{.underline}**

**C** - All patients with heart failure should be advised to refrain
from excessive alcohol consumption. When the aetiology of heart failure
is alcohol related, patients should be strongly encouraged to stop
drinking alcohol.

**B** - Patients with chronic heart failure should be strongly advised
not to smoke and should be offered smoking cessation advice and support.

**B** - Motivational techniques should be used to promote regular low
intensity physical activity amongst patients with stable heart failure.

**[Pharmacological Therapies]{.underline}**

**A** - Angiotensin converting enzyme inhibitors should be considered in
patients with all New York Heart Association (NYHA) functional classes
of heart failure due to left ventricular systolic dysfunction.

**A** - All patients with heart failure due to left ventricular systolic
dysfunction of all NYHA functional classes should be started on
beta-blocker therapy as soon as their condition is stable *(unless
contraindicated by a history of asthma, heart block or symptomatic
hypotension)*.

**A** - Patients with chronic heart failure due to left ventricular
systolic dysfunction alone, or heart failure, left ventricular systolic
dysfunction or both following myocardial infarction who are intolerant
of angiotensin converting enzyme inhibitors should be considered for an
angiotensin receptor blocker.

**B** - Patients with heart failure due to left ventricular systolic
dysfunction who are still symptomatic despite therapy with an
angiotensin converting enzyme inhibitor and a beta-blocker may benefit
from the addition of candesartan, following specialist advice.

**B** - Following specialist advice, patients with moderate to severe
heart failure due to left ventricular systolic dysfunction should be
considered for spironolactone unless contraindicated by the presence of
renal impairment or a high potassium concentration.

**B** - Patients who have suffered a myocardial infarction and with left
ventricular ejection fraction [\<]{.underline}40% and either diabetes or
clinical signs of heart failure should be considered for eplerenone
unless contraindicated by the presence of renal impairment or a high
potassium concentration.

**B** - Diuretic therapy should be considered for heart failure patients
with dyspnoea or oedema *(ankle or pulmonary)*.

**A** - Digoxin should be considered as an add-on therapy for heart
failure patients in sinus rhythm who are still symptomatic after optimum
therapy.

**A** - African American patients with advanced heart failure due to
left ventricular systolic dysfunction should be considered for treatment
with hydralazine and isosorbide dinitrate in addition to standard
therapy.

**B** - Patients who are intolerant of an angiotensin converting enzyme
inhibitor and an angiotensin II receptor blocker due to renal
dysfunction or hyperkalaemia should be considered for treatment with a
combination of hydralazine and isosorbide dinitrate.

**D** - Patients with chronic heart failure should receive one
pneumococcal vaccination and an annual influenza vaccination.

**[Interventional Procedures]{.underline}**

**Patients with Left Ventricular Systolic Dysfunction**

**A** - For patients in sinus rhythm with drug refractory symptoms of
heart failure due to left ventricular systolic dysfunction *(left
ventricular ejection fraction* [\<]{.underline}*35%)* and who are in
NYHA class III or IV and who have a QRS duration of \>120 ms, cardiac
resynchronisation should be considered.

**B** - Patients with obstructive sleep apnoea and heart failure may be
safely treated with continuous positive airway pressure.

**B** - Consideration should be given to enrolling stable heart failure
patients who are in NYHA class II -- III into a moderate intensity
supervised exercise training programme to give improved exercise
tolerance and quality of life.

**Surgical Assessment and Intervention**

**B** - In patients undergoing coronary artery bypass grafting with left
ventricular ejection fraction [\<]{.underline}35% consideration should
be given to preoperative introduction of intraaortic balloon
counterpulsation.

**[Models of Care]{.underline}**

**Post-Discharge Care**

**A** - Comprehensive discharge planning should ensure that links with
post-discharge services are in place for all those with symptomatic
heart failure. A nurse led, home based element should be included.

**A** - Follow up *(including by telephone)* by trained heart failure
nurses should be considered for patients post-discharge or with stable
heart failure. Nurses should have the ability to alter diuretic dose and
the interval between telephone calls, and recommend emergency medical
contact.

**A** - Patients with heart failure should be offered multidisciplinary
follow up, including pharmacy input to address knowledge of drugs and
compliance. Follow up should include feedback to clinicians about
possibilities for optimising pharmacological interventions.

Refer to the original guideline document for a discussion of palliative
care for patients with chronic heart failure.

**[Definitions]{.underline}**:

**Grades of Recommendation**

*Note: The grade of recommendation relates to the strength of the
evidence on which the recommendation is based. It does not reflect the
clinical importance of the recommendation.*

**A**: At least one meta-analysis, systematic review of randomized
controlled trials (RCTs), or RCT rated as 1++ and directly applicable to
the target population; *or*

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**: A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 1++ or 1+

**C**: A body of evidence including studies rated as 2+, directly
applicable to the target population and demonstrating overall
consistency of results; *or*

Extrapolated evidence from studies rated as 2++

**D**: Evidence level 3 or 4; *or*

Extrapolated evidence from studies rated as 2+

**Good Practice Points**: Recommended best practice based on the
clinical experience of the guideline development group

**Levels of Evidence**

**1++**: High quality meta-analyses, systematic reviews of randomised
controlled trials (RCTs), or RCTs with a very low risk of bias

**1+**: Well-conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias

**1-**: Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias

**2++**: High quality systematic reviews of case control or cohort
studies\
High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**: Well-conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**: Case control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not causal

**3**: Non-analytic studies (e.g. case reports, case series)

**4**: Expert opinion

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document for the
assessment of suspected chronic heart failure.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate management of chronic heart failure

#### POTENTIAL HARMS

-   Important adverse effects of angiotensin converting enzyme
    inhibitors are cough, hypotension, renal impairment and
    hyperkalaemia. Angio-oedema is a rare adverse effect, which can be
    life threatening (due to laryngeal involvement). Renal impairment is
    likely to occur in those with unsuspected (bilateral) renovascular
    disease. Angiotensin converting enzyme inhibitor induced renal
    dysfunction is a possible indicator of renovascular disease.

-   In the short term, *beta blockers* can produce decompensation with
    worsening of heart failure and hypotension.

-   *Spironolactone* can produce gynaecomastia, hyperkalaemia, and renal
    dysfunction

-   Although *eplerenone* produces less gynaecomastia than
    spironolactone, it can still produce hyperkalaemia and renal
    dysfunction and blood urea.

-   *Loop diuretics* can cause an elevated urate level and may
    precipitate gout

-   Evidence of benefit must be weighed against the possibility of an
    increase in sudden deaths associated with *digoxin*. The risk of
    *digoxin* toxicity is increased by hypokalaemia.

-   Other important cautions and drug interactions of pharmacological
    therapies are listed in the annexes of the original guideline
    document.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Beta-blockers are contraindicated in patients with:

    -   Asthma

    -   Heart block or heart rate \<60/min

    -   Persisting signs of congestion, hypotension/low blood pressure
        (systolic\<90 mm Hg), raised jugular venous pressure, ascites,
        marked peripheral oedema

-   Spironolactone is contraindicated in patients whose baseline serum
    potassium is \>5 mmol/l or serum creatinine is \>220 micromol/l.
    Such patients are particularly likely to suffer the adverse effects
    of hyperkalaemia or renal dysfunction.

-   Eplerenone is contraindicated by the presence of renal impairment or
    high potassium concentration.

-   Angiotensin converting enzyme inhibitors are contraindicated in
    patients with a history of angioneurotic oedema or with known
    bilateral renal artery stenosis.

-   Angiotensin receptor blockers are contraindicated in patients with:

    -   History of angioneurotic oedema

    -   Known bilateral renal artery stenosis

-   Diltiazem and verapamil are generally contraindicated in congestive
    heart failure.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline is not intended to be construed or to serve as a standard
of care. Standards of care are determined on the basis of all clinical
data available for an individual case and are subject to change as
scientific knowledge and technology advance and patterns of care evolve.
Adherence to guideline recommendations will not ensure a successful
outcome in every case, nor should they be construed as including all
proper methods of care or excluding other acceptable methods of care
aimed at the same results. The ultimate judgement must be made by the
appropriate healthcare professional(s) responsible for clinical
decisions regarding a particular clinical procedure or treatment plan.
This judgement should only be arrived at following discussion of the
options with the patient, covering the diagnostic and treatment choices
available. It is advised, however, that significant departures from the
national guideline or any local guidelines derived from it should be
fully documented in the patient\'s case notes at the time the relevant
decision is taken.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Implementation of national clinical guidelines is the responsibility of
each National Health Services (NHS) Board and is an essential part of
clinical governance. It is acknowledged that every Board cannot
implement every guideline immediately on publication, but mechanisms
should be in place to ensure that the care provided is reviewed against
the guideline recommendations and the reasons for any differences
assessed and, where appropriate, addressed. These discussions should
involve both clinical staff and management. Local arrangements may then
be made to implement the national guideline in individual hospitals,
units and practices, and to monitor compliance. This may be done by a
variety of means including patient-specific reminders, continuing
education and training, and clinical audit.

Key points for audit are identified in the original guideline document.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators\
Chart Documentation/Checklists/Forms\
Clinical Algorithm\
Foreign Language Translations\
Patient Resources\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Scottish Intercollegiate Guidelines Network (SIGN). Management of
chronic heart failure. A national clinical guideline. Edinburgh
(Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2007
Feb. 53 p. (SIGN publication; no. 95). \[155 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1999 Feb (revised 2007 Feb)

#### GUIDELINE DEVELOPER(S)

Scottish Intercollegiate Guidelines Network - National Government Agency
\[Non-U.S.\]

#### SOURCE(S) OF FUNDING

Scottish Executive Health Department

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Guideline Development Group*: Professor Allan Struthers (*Chair*)
Consultant Physician, Ninewells Hospital and Medical School, Dundee; Ms
Gillian Armstrong, Senior 1 Physiotherapist, Glasgow Royal Infirmary; Ms
Lynda Blue, Heart Failure Nurse Co-ordinator, Western Infirmary,
Glasgow; Ms Joyce Craig, Senior Health Economist, NHS Quality
Improvement Scotland; Dr Martin Denvir, Consultant Cardiologist, Western
General Hospital, Edinburgh; Dr Geoff Dobson, General Practitioner,
Edinburgh; Dr Barbara Dymock, Associate Specialist in Palliative
Medicine, Royal Victoria Hospital, Dundee; Dr Andrew Elder, Consultant
in Acute Elderly Medicine, Western General Hospital, Edinburgh; Ms
Trisha Graham, Physiotherapist, Stobhill General Hospital, Glasgow; Dr
Hamish Greig, General Practitioner, Brechin; Mr Robin Harbour, Quality
and Information Director, SIGN Executive; Dr Kerry-Jane Hogg, Consultant
Cardiologist, Stobhill General Hospital, Glasgow; Mr Steve McGlynn, Area
Pharmacy Specialist, Glasgow; Professor John McMurray, Consultant
Cardiologist, Western Infirmary, Glasgow; Dr Caroline Morrison, Public
Health Consultant, Greater Glasgow Health Board; Mr Andrew Murday,
Consultant in Cardiothoracic Surgery, Glasgow Royal Infirmary; Dr Moray
Nairn, Programme Manager, SIGN Executive; Dr David Northridge,
Consultant Cardiologist, Western General Hospital, Edinburgh; Ms Agnes
Sloey, Clinical Co-ordinator for Cardiology, Wishaw General Hospital; Mr
Peter Thompson, Patient Representative, Edinburgh; Dr Deborah Tinson,
Chartered Clinical Psychologist, Astley Ainslie Hospital, Edinburgh

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Declarations of interests were made by all members of the guideline
development group. Further details are available from the Scottish
Intercollegiate Guidelines Network (SIGN) Executive.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Diagnosis and treatment of
heart failure due to left ventricular systolic dysfunction. Edinburgh
(Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 1999. 68
p. (SIGN publication; no. 35).

This guideline was issued in 2007 and will be considered for review in
three years. Any updates to the guideline in the interim period will be
noted on the [Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/new.html).

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Scottish Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/pdf/sign95.pdf).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Quick reference guide: Heart disease. Edinburgh (Scotland): Scottish
    Intercollegiate Guidelines Network, 2007 Feb. 31 p. Available in
    Portable Document Format (PDF) from the [Scottish Intercollegiate
    Guidelines Network (SIGN) Web
    site](http://www.sign.ac.uk/pdf/qrgchd.pdf).

-   SIGN 50: A guideline developer\'s handbook. Edinburgh (Scotland):
    Scottish Intercollegiate Guidelines Network. (SIGN publication; no.
    50). Available from the [SIGN Web
    site](http://www.sign.ac.uk/methodology/index.html).

-   Appraising the quality of clinical guidelines. The SIGN guide to the
    AGREE (Appraisal of Guidelines Research & Evaluation) guideline
    appraisal instrument. Edinburgh (Scotland): Scottish Intercollegiate
    Guidelines Network, 2001. Available from the [SIGN Web
    site](http://www.sign.ac.uk/methodology/agreeguide/index.html).

-   Management of coronary heart disease: A national clinical and
    resource impact assessment. Edinburgh (Scotland): Scottish
    Intercollegiate Guidelines Network, 2007 Feb. 120 p. Available in
    Portable Document Format (PDF) from the [SIGN Web
    site](http://www.sign.ac.uk/pdf/chdaudit.pdf).

-   Excel spreadsheets to assist health boards to estimate their local
    costs (used in conjunction with the national clinical and resource
    impact assessment). Edinburgh (Scotland): Scottish Intercollegiate
    Guidelines Network, 2007 Feb. Available from the [SIGN Web
    site](http://www.sign.ac.uk/guidelines/published/support/guideline93-97/excel.html).

#### PATIENT RESOURCES

The following is available:

-   Chronic heart failure for patients. Edinburgh (Scotland): Scottish
    Intercollegiate Guidelines Network, 2007 Feb. 26 p.

Available in Portable Document Format (PDF) from the [Scottish
Intercollegiate Guidelines Network (SIGN) Web
site](http://www.sign.ac.uk/pdf/pat95.pdf). Urdu translation is also
available from the [SIGN Web
site](http://www.sign.ac.uk/pdf/pat95urdu.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on January 3, 2002. The information
was verified by the guideline developer as of February 4, 2002. This NGC
summary was updated by ECRI Institute on April 24, 2007.

#### COPYRIGHT STATEMENT

Scottish Intercollegiate Guidelines Network (SIGN) guidelines are
subject to copyright; however, SIGN encourages the downloading and use
of its guidelines for the purposes of implementation, education, and
audit.

Users wishing to use, reproduce, or republish SIGN material for
commercial purposes must seek prior approval for reproduction in any
medium. To do this, please contact <sara.twaddle@nhs.net>.

Additional copyright information is available on the [SIGN Web
site](http://www.sign.ac.uk/guidelines/published/copyright.html).

### DISCLAIMER

#### NGC DISCLAIMER

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Guidelines represented on the NGC Web site are submitted by guideline
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Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

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Date Modified: 11/3/2008