Hello, it’s been a while since I wrote a heart failure blog hasn’t it! I’ve been working on different Oberoi Disease Programmes; the variety has been great; however, it is time for me to return to the depths of the myocardium. The heart strings are pulling me!
There have been several changes to the NICE Heart Failure Guidelines this year following further research and expert narrative around the management of HFrEF, HFmrEF and HFpEF (or also known as Heart Failure with Normal Ejection Fraction). Professionals’ opinions are somewhat diverse when it comes to the management of HFpEF it seems, however, the consensus is towards treating HFpEF more systematically.
Let’s look at the new additions to the NICE HF Update (NICE, 2025) for these 3 types of Heart Failure.
In summary, I have pulled together the key changes which provides some, not all clarification needed on managing patients with heart failure.
The multidisciplinary team and prescribing – this has been clarified and especially relevant for those primary care clinicians who have heart failure expertise in prescribing i.e. a nurse specialist or a pharmacist. It’s disappointing to see the omission of the nurse specialist as an example here.
“The specialist heart failure multidisciplinary team (MDT) should work in collaboration with the primary care team, and should include a:
- lead physician with subspecialty training in heart failure (usually a consultant cardiologist) who is responsible for making the clinical diagnosis
- specialist heart failure nurse
- healthcare professional with expertise in specialist prescribing for heart failure, for example, a specialist heart failure pharmacist.[2018, amended 2025]”
Natriuretic peptides
The wording has been elaborated upon regarding type of heart failure and the relevance of interpreting results alongside other co-morbidities.
“The level of serum natriuretic peptide does not differentiate between heart failure with preserved, mildly reduced and reduced ejection fraction.[2018, amended 2025]”
“High levels of serum natriuretic peptides can have causes other than heart failure (for example, pulmonary, renal, liver and systemic pathologies, sepsis, chronic obstructive pulmonary disease, diabetes, or cirrhosis of the liver).[2010, amended 2025]”
Management of Heart Failure with Reduced Ejection Fraction (HFrEF) (i.e ≤40%)
The guidance includes both newly diagnosed patients with heart failure and those with preexisting heart failure.
“Offer an angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist (MRA) and a sodium-glucose cotransporter-2 (SGLT2) inhibitor to people with heart failure with reduced ejection fraction.[2025]”
“For people on the maximum tolerated dose of each of the 4 medicines who continue to have symptoms of heart failure, consider switching the ACE inhibitor to an angiotensin receptor-neprilysin inhibitor (ARNI). [2025]”
Patients who are intolerant to ACEI (non-angio-oedema related)
“For people with heart failure with reduced ejection fraction who have symptoms of intolerance to ACE inhibitors (other than angioedema), offer an ARNI, beta-blocker, MRA and SGLT2 inhibitor. [2025]”
Patients who have experienced a angio-oedema response to ACEI who are also intolerant of ARNIs
“For people with angioedema after taking an ACE inhibitor, or who have symptoms of intolerance to ARNIs:
- offer a beta-blocker, MRA and SGLT2 inhibitor and
- consider an ARB. [2025]”
Please note, the prescribing of an ARB where angio-oedema has already occurred with an ACEI should trigger extreme caution in decision-making for these patients.
Patients who are unable to tolerate ACEI/ARB or ARNI can be considered for Hydralazine in combination with nitrate
“If ACE inhibitors, ARNIs and ARBs are not tolerated, seek specialist advice and consider hydralazine in combination with nitrate. [2010, amended 2025]”
For completion, the guidance includes further reference to the use of Digoxin in addition to all 4 pillars of heart failure prescribing
“Offer digoxin to people with worsening or severe heart failure with reduced ejection fraction despite optimised treatment combinations as detailed in recommendations 1.4.1 to 1.4.4. Seek specialist advice before starting treatment. [2010, amended 2025]”
Intravenous iron therapy
In those with HFrEF iron status should be routinely checked and include the following blood tests:
- transferrin saturation (TSAT)
- serum ferritin
- haemoglobin. [2025]
“Consider Iron Sucrose, Ferric Carboxymaltose or Ferric Derisomaltose for people with heart failure with reduced ejection fraction and haemoglobin of less than 150g per litre if they have iron deficiency defined as:
- TSAT of less than 20% or
- serum ferritin of less than 100nanogram per ml. [2025]”
As we know, patients with heart failure are already breathless and the complications of anaemia only make symptoms worse for patients, affecting their quality of life. The guidance welcomes the use of intravenous iron in these patients to improve symptoms and patient quality of life. It goes without saying, we must not assume iron deficiency is caused solely by chronic cardiac stress and we must ensure clinicians consider further investigations for other explanations of anaemia.
“If iron deficiency anaemia is identified, do not assume that it is related to the person’s heart failure and think about investigating for alternative causes. [2025]”
Management of Heart Failure with mid-range Ejection Fraction (HFmrEF) (i.e. ≥41-49%)
The debate regarding this group of patients has been going on for some time around whether you treat the patient the same who has EF42% Vs EF48%. In real practice, we are guided by the severity of the patient’s symptoms but not completely. For example, I have come across several patients with a higher EF who appear symptomatic versus those with a lower EF% who have fewer symptoms. What we must remember is the subjectivity around echocardiography interpretation and rounding up/down when the EF is calculated. These patients should be treated in line with the updated guidance. It’s worth pointing out that if a patient is presenting not quite as expected, then it’s important to recheck reports/consider other checks/opinion and alternative differential diagnoses. Patients can present oddly, the most memorable to date for myself, is a patient with an EF 9% with no symptoms (the Echocardiogram was repeated, and the patient had a cardiac MRI to confirm the same result). To summarise, HFmrEF patients should be considered for the following therapies:
“Consider an angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist (MRA) and a sodium-glucose cotransporter-2 (SGLT2) inhibitor for treating heart failure with mildly reduced ejection fraction. See also recommendation 1.5.3. [2025]”
“For people who have symptoms of intolerance to ACE inhibitors, consider an angiotensin-receptor blocker (ARB), a beta-blocker, an MRA and an SGLT2 inhibitor. See also recommendation 1.5.3 [2025]”
Management of Heart Failure with Preserved (or normal) Ejection Fraction (i.e. ≥50%)
Following the inclusion of SGLT2i therapies for heart failure in the NICE technology appraisal recommendations; the NICE guidance update now clearly states this pharmacological therapy can be considered, where appropriate, for patients with HFpEF.
In addition to this, MRAs alongside SGLT2i therapy can be considered for patients with this type of heart failure. This is the most significant change in the update in my opinion. Often treated with loop diuretics previously, some clinicians are moving towards these two types of therapies in preference. Renal monitoring should be adhered to as there were increased risks of hyperkalaemia in these patients.
The FINEARTS study (2025) population looked at the use of MRAs in HFpEF; some of you will remember the neutral study result with the TOPCAT study (2014) which did not change clinical practice. The HF update (2025) following evidence from the Italian FINEARTS study summarised:
“Evidence showed treatment with a mineralocorticoid receptor antagonist (MRA) reduced hospitalisation for heart failure and may also improve all-cause and cardiovascular mortality in people with heart failure with preserved ejection fraction. However, there was an increased risk of hyperkalaemia. Although this requires careful monitoring and management the committee agreed this should not prevent them from recommending MRAs for this population group”
Renal monitoring patients with heart failure
Renal function is rarely normal in the heart failure population with many patients having CKD3 as a baseline. Clinicians are often concerned about worsening renal function in this group of patients and NICE have updated the renal monitoring advice below:
“If the person’s eGFR is 45ml per minute per 1.73m2 or less, consider lower starting doses and smaller dose increments for the medicine combinations covered by recommendations 1.4.1, 1.4.3, 1.4.4, and 1.5.1 to 1.5.5. [2018, amended 2025]”
“If the person’s eGFR is less than 30ml per minute per 1.73m2, the specialist heart failure multidisciplinary team (MDT) should consider liaising with a renal physician. [2018, amended 2025]”
Some patients remain very complex, and we need to seek opinion from the wider MDT; this should not be seen as a negative or a failure, quite the opposite!
I urge to you have a read of the full guidance which also refers to individual medication group guidance, such as the need for a baseline ECG prior to initiating beta-blockers. It is good to see this common-sense good practice point in the actual guidance.
That’s all from me this time, please do look up the updated guidance for heart failure at
https://www.nice.org.uk/guidance/ng106
Bye for now, Amanda
References:
NICE Guidance 2025
https://www.nice.org.uk/guidance/ng106
FINEARTS study 2025
https://pubmed.ncbi.nlm.nih.gov/40248308/
HFmrEF & HFpEF TA Appraisal for the use of SGLT2i
https://www.nice.org.uk/guidance/TA902 (2023)
https://www.nice.org.uk/guidance/ta929 (2023)
HFrEF TA Appraisals for use of SGLT2i
https://www.nice.org.uk/guidance/ta679 (2022)
https://www.nice.org.uk/guidance/ta773 (2023)
TOPCAT study