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Chronic heart failure deaths in England could be cut by around 3,000 per year following the introduction of updated guidance on treatment for the condition, the National Institute for Health and Care Excellence (NICE) has said.
In a statement published on 10 June 2025 alongside draft updated guidance, NICE also said that the recommendations in ‘Chronic heart failure in adults: diagnosis and management‘ could prevent around 5,000 hospital admissions annually.
The guidance said that the four main treatment types for heart failure with a reduced ejection fraction (HFrEF) are now being used earlier in patient treatment than previously offered “without the need to optimise the dose of any one medicine before introducing another”.
The four treatments are angiotensin-converting enzyme (ACE) inhibitor, beta-blocker (BB), mineralocorticoid receptor antagonist (MRA) and sodium-glucose cotransporter-2 (SGLT2) inhibitor.
The updated guidance “reflects this change in practice” and also recommends “an earlier use of the SGLT2 inhibitors empagliflozin and dapagliflozinthan we’ve recommended before”, NICE added.
“It means they can be offered at any stage of the treatment pathway, instead of only when other medicines have been fully titrated, a process that can take over a year.”
Both SGLT2 inhibitors and angiotensin receptor-neprilysin inhibitors (ARNIs) can be started by GPs, under advice from a heart failure specialist, “rather than solely by a heart failure specialist, potentially speeding up access to these important treatments”, the guidance said.
According to the consultation documents, the NICE committee said that evidence showed adding an SGLT2 inhibitor to existing treatment with an ACE inhibitor or angiotensin II receptor blocker (ARB), beta-blocker and an MRA reduced heart failure mortality and hospitalisation without important increases in adverse events.
Economic modelling “suggested that early use of an MRA and SGLT2 inhibitor in combination with ACE inhibitor and beta-blocker would be cost-effective”, the documents said.
“For this reason and because the correct sequencing of medicines will vary from one person to another, the committee agreed to move away from a set of recommendations that include a sequence for introducing each medicine and instead listed treatment combinations for different scenarios.”
Paul Wright, consultant cardiovascular pharmacist at Barts Health NHS Trust, described the updated guidance as “great news”.
“European guidance has recommended four agents be used at initiation of HFrEF in the 2021 update, whereas guidance from NICE (2018) has recommended a sequential addition based on earlier trials and has been in need of an update to incorporate new data over the last eight years. These updates will be aligning us with the ESC [European Society of Cardiology] guidance,” he said.
“The big game changer for me is the suggestion that ARNI — i.e. Entresto (sacubutril valsartan) — will be able to be started by primary care on advice of the heart failure team; the current (NICE) TA [technology appraisal] has restricted initiation to the heart failure team only. A move to support primary care initiate of ARNI is brilliant and is going to have a significant impact, as currently its uptake is significantly less than predicted, leaving a large number of eligible patients unable to receive this treatment.”
“To be able to offer patients these medicines more quickly is really exciting,” Wright added.
Eric Power, deputy director at NICE’s centre for guidelines, said: “For this update, we’ve been able to review the emerging evidence quickly to keep pace with changes in the treatment landscape and make recommendations that will widen access to effective treatments.
“This should have a big impact on the lives of people living with heart failure, as well as freeing up space in hospitals by reducing their risk of having to go to hospital for unplanned emergency treatment.”
The draft guidance is open for consultation until 8 July 2025.
