New chronic heart failure guidance: what does it mean for practice? (transcription)

The audio transcript from this episode of The Pharmaceutical Journal’s PJ Pod.

Caitlin: Hello and welcome to another learning episode of The PJ Pod, brought to you by The Pharmaceutical Journal, the Royal Pharmaceutical Society’s official journal. 

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I’m Caitlin Killen and in this episode, part of the November 2025 digital issue, we’ll be discussing the recently updated chronic heart failure guidance from the National Institute for Health and Care Excellence or ‘NICE’.

For the first time, the guidance mentions pharmacists specifically as part of the multidisciplinary team, recognising the vital role pharmacists play in the care of patients with heart failure. 

Published in September 2025, the guidance makes several new recommendations about the pharmacological management of the condition. So for this episode, we wanted to find out more about the basis for these recommendations; their implications for the clinical management of chronic heart failure; and how they are already being integrated in practice.

To do this, I spoke to consultant cardiovascular pharmacist Paul Wright from Barts Health NHS Trust, who talked me through the changes.

He started off by explaining that the update was long overdue.

Paul: I mean, there’s been seven years since the last guidance was published, so there’s been quite a lot of papers and developments that have gone on over that time period. 

We know that, within secondary care, the clinicians have often been using the more recently updated ESC guidance and, in terms of treatment pathways, the NICE guidance has aligned itself with some of the more up-to-date treatment algorithms that we see from the likes of ESC and AHA. And, in particular, a movement away from this step-wise progression of agents to the combination of agents added much, much earlier. 

Caitlin: The fact that the guidance now reflects what is already being done in practice has been well received by healthcare professionals involved in the management of heart failure.

Paul: So, the guidance has been a month and, I think certainly, locally, there’s been a lot of… I’m gonna use the word excitement around the heart failure clinicians and the heart failure teams within secondary care. I think that it’s a welcome relief and, again, many of our secondary care colleagues have been utilising these agents in line with the ESC-based guidance, which had a four pillars approach for some time now. 

Caitlin: The four pillars approach to heart failure refers to the four main classes of medication recommended to manage the condition and how these medicines are used together. 

Paul: And what we see now in the new guidance is alignment with the European and other guidance, which is about looking at combination therapy and adding in four pillars, as you were, to ensure that we can do the best for patients.

It’s really important that patients are still titrated, so once you get patients onto the four different therapeutic classes — which are an ACE, beta blocker, mineralocorticoid receptor antagonist, and an SGLT2 inhibitor. Once patients are on four pillars, you then look to titrate to the maximum tolerated dose because we know that at the higher doses, we can do and offer more for patients’ benefit. 

Caitlin: Paul told me about some work they’ve already done at St Barts that has helped the implementation of this four pillars approach

Paul: One of the projects we’ve done within the Barts Heart Centre is looking at initiating patients and optimising patients on a virtual platform. And we’ve developed a pathway called Start-HF, where individuals across the ICB spanning several hospitals are on a virtual platform for optimisation of their heart failure therapy. And this is essentially run by pharmacists with a consultant heart failure oversight and patients are rapidly titrated.

The guys see around 50 to 60 patients a week and they make several touchpoints with individuals, where therapy is up-titrated. And we’ve shown over a nine-month period that individuals can be titrated up to the four pillars. And then at the point of discharge, around 92% of our patients are on the four pillars. And this is undertaken between six to eight weeks, and patients are able to then be transferred back to primary care for ongoing maintenance review and monitoring. This has significantly reduced outpatient appointment activity, significantly reduced in-patient rehospitalisations and has had a big impact on an improvement in LV function, meaning that many of these patients now don’t need to receive device therapy.

Caitlin: The updated NICE guidance makes recommendations for how heart failure should be managed, in line with the four pillars approach, based on its classification. Heart failure can be classified in many different ways, but the most common way to classify it, is by the ejection fraction, which is a measure of how much blood your heart pumps out with each contraction, expressed as a percentage.

Paul: And we see an ejection fraction of 40% or lower being referred to as heart failure with reduced ejection fraction. Heart failure with preserved ejection fraction typically is with an ejection fraction of over 50%. And, for some time, there’s been this grey zone or grey area of mid-range or mildly reduced ejection fraction of between 40 to 50, where guidelines have not really tackled what we should be doing within this cohort. 

Caitlin: First, Paul told me how heart failure with reduced ejection fraction should be managed.

Paul: So, for heart failure and reduced ejection fraction, we’ve seen a big change from the previous guidance to the newer guidance and a suggested this movement away from the stepwise addition, which takes a long time to achieve, and indeed many patients not actually being given the opportunity to be fully optimised on all the heart failure therapies that are available.

Caitlin: When it comes to heart failure with preserved ejection fraction or ‘HEF PEF’ for short, there haven’t historically been many good management options.  

Paul: Essentially what we were able to do is to offer diuretic therapy for symptom management and then we would be looking to optimise their cardiovascular risk factors — so things like optimising blood pressure control, optimizing their diabetes control — and control of heart rate in atrial fibrillation. We now have a few more options, and the latest guidance suggests that we can consider offering a mineralocorticoid receptor antagonist and we can also consider offering an SGLT2 inhibitor.

Caitlin: And luckily for this specific patient cohort, there are other treatments on the horizon.

Paul: In the not-too-distant future, I think over the next 12 months or so, there will be more agents that are going to be appraised and offered within those individuals with heart failure with preserved ejection fraction. We’ve seen data for finerenone — a non-steroidal mineralocorticoid receptor antagonist — with good outcomes at reducing hospitalisation combined with mortality. We also see some positive data for the GLP-1 inhibitor tirzepatide. So again, watch this space. I think we’re going to see some of these being licensed and endorsed through NICE after appraisal for those individuals with HFpEF. 

Caitlin: Previously, guidance on management of heart failure with mildly reduced ejection fraction, also known as HeFMrEF, has been lacking.

Paul: The mid range is quite interesting, and many guidance have, have been, they’ve essentially ignored the HFMrEF cohort of patients. I think with the availability of generic agents, and I think that’s because much of heart failure, we’re kind of understanding this is a continuum or a spectrum and, as such, there is guidance now to suggest that individuals with HFrEF — this mid range or mildly reduced ejection fraction — should also be initiated on these four pillars of therapy, so ACE, beta blocker, MRA and an SGLT2 inhibitor. 

Caitlin: As well as specific recommendations for the different classifications, there are also new recommendations relating to the indication of IV iron in patients with heart failure and an annual review of haemoglobin and transferrin saturation. 

Paul: There is now guidance and levels at which would prompt IV iron to be administered.

I think this is going to have implications for services delivering IV iron. And I think we’re also gonna have to link up better with our primary care colleagues, as individuals get picked up for a need for IV iron, to then have that delivered in a safe manner. And again, whether or not there are going to be pathway updates, both to look for iron deficiency, but also thinking about how you’re going to administer. And we may see community hubs being set up for IV iron administration.  

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Caitlin: So, that’s it for changes to the recommendations for pharmacological management of heart failure. But I wanted to know if these changes would impact patients already initiated on therapy.

Paul: So these guidelines will certainly have an impact on patients that have started the journey and also those patients that have maybe started a journey, got a little bit better, and then been discharged or kind of left on their own. So, the updated guidance very much is suggesting that individuals with heart failure with reduced ejection fraction and heart failure with mildly reduced ejection fraction should be on these four pillars. And I am hopeful that with the guidance and the support that we have within the materials of the updated guidance, we can and should be looking to change pathways and we can and should be looking to get individuals on these agents.

Caitlin: Another way that these recommendations could improve patient care is by the standardisation of the care pathway.

Paul: One of the other key changes within medicines are the individuals that can support and titrate therapy. So we’ve seen previously, there’s quite a discord with how heart failure is managed in primary, secondary and community settings, with resource allocation and team set-ups being markedly different up and down the country and within boroughs within ICBs. And here we can see the NICE guidance trying to standardise the care that’s given by suggesting that primary care take on a little bit more of the initiation and maintenance of these patients to ensure that there’s no gaps as patients flick and move between primary/secondary care services.  

Caitlin: Speaking of primary care, previously sacubitril/valsartan could only be initiated and titrated in secondary care. This guidance changes that.

Paul: With this I think we see a positive change for another agent in heart failure —sacubitril/valsartan — and it has been mentioned specifically in the guidance here that this can be initiated in primary care under the direction of a heart failure specialist within secondary care. And I think if we look at the uptake of sacubitril/valsartan, it’s typically been very low, and that’s because the initiation and often dose titrations has been required to be undertaken in secondary care. And what we have now in the updated guidance is the direction of this can be initiated and titrated within primary care. I’m very hopeful that this will allow better access to individuals that meet criteria to be fully optimised on a very effective heart failure therapy.  

Caitlin: I was keen to hear what support primary care pharmacists may need with this change.

Paul: I think that the management and expectation of heart failure for too long has been on this stepwise approach. And, despite updates from the European Society Cardiology and despite some of the practice changing within secondary care that are now very familiar with the concept of the four pillars, I think this is a relatively new concept for those prescribing in primary care. So I think we’ve got a lot of education to do to support that.

Caitlin: Another change needed to support the use of sacubitril/valsartan in primary care is the updating of local formularies.

Paul: I think that the sacubitril/valsartan is most likely going to have to go back to formularies to be updated in a move away from secondary care initiation and maintenance to one of, can be done on the advice of a specialist. So, I think that for those who are working across ICBs and within formulary areas, I think watch this space. I think there’s gonna be a number of applications coming in looking to update those guidance.

Caitlin: That’s it for today’s episode on the updated heart failure guidance. I hope it’s given you some useful insight into NICE’s updated recommendations and some of the additional considerations needed for them to be implemented in practice. We’ll leave links to the guidance and other useful resources in the show notes.

I’d like to say a big thank you to Paul for walking us through the updates. 

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That’s it from us. Until next time — good bye.