Disease management guideline for chronic heart failure revised in Germany

The National disease management guideline for chronic heart failure with recommendations for diagnostics and therapy has been revised. It is now available free of charge on the internet pages of the Medical Center for Quality in Medicine.

Heart failure is the most common cause of hospital admissions in Germany and is one of the leading causes of death. The aim of the National Disease Management Guideline (NVL) is to improve the care of patients with chronic heart failure.

For this purpose, recommendations are made for diagnosis and therapy, but also for the coordination between GPs and specialists as well as between outpatient and inpatient care.

For the third edition of the guideline, the contents of the chapters on diagnostics, treatment planning, non-drug therapy, comorbidities, acute decompensation, rehabilitation, and palliative care were completely revised. The contents of the chapters on drug and invasive therapy and on care coordination, which have already been updated for the second edition (2017), were reviewed and confirmed.

The most important insights of the third edition of the guideline are presented below.

• Diagnostics
  • If there is a suspicion of heart failure according to the anamnesis and laboratory diagnosis, transthoracic echocardiography should be performed. Costly diagnostic measures, particularly invasive ones, should only be carried out if this can lead to therapeutic consequences
• Drug therapy:
  • Patients with reduced ejection fraction should receive angiotensin-converting-enzyme (ACE) inhibitors or sartans, beta-blockers, and in the absence of symptom control, mineralocorticoid receptor antagonists; for edema, diuretics are indicated. Ivabradine and sacubitril / valsartan should be used in case of contraindications or if the correctly adjusted basic medication does not adequately relieve symptoms
  • For nonspecific symptoms such as dyspnea of unclear cause, brain natriuretic peptide (BNP) or N-terminal-pro hormone BNP (NT-proBNP) should be determined to exclude heart failure if referral for echocardiography for the patient is associated with severe stress. In contrast, the peptide-value-guided therapy or the routine determination in the ambulatory follow-up is not recommended
• Instrumental therapy:
  • Not every patient with heart failure benefits from the implantation of a defibrillator, cardiac resynchronization therapy (CRT), or another supporting system. After thorough information, the expected benefits should be weighed against possible disadvantages together with the patient
• Structured care:
  • All patients with heart failure should be included in a structured program. Patients with a poor prognosis should be given more intensive care, for example, by involving specialized nurses, additional telephone support, or telemedicine

In the course of the revision of the NVL, further patient sheets for critical decision-making or informational situations were developed. A total of 18 patient information on heart failure is available. These include decision support on the various pacemakers, nutrition tips, vaccination recommendations and warnings about specific medications. These evidence-based materials in easy-to-understand language are designed to assist clinicians in advising patients to help them make informed decisions.

The full details in German can be found here. The third edition of the National disease management guideline for chronic heart failure can be obtained here.

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