NICE vs ESC: Management of Heart Failure (2025)

NICE vs ESC: Management of Heart Failure (2025) - A Clinical Comparison

This guide provides a detailed, factual comparison of the 2023 National Institute for Health and Care Excellence (NICE) guideline NG106 (updated 2023/24) and the 2023 European Society of Cardiology (ESC) guideline for the diagnosis and treatment of acute and chronic heart failure. It is intended to help UK clinicians understand key similarities and differences to inform local practice, which must operate within the context of the NHS.

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Diagnosis and Initial Assessment

NICE Approach

NICE provides a stepwise, primary-care-friendly pathway strongly aligned with NHS resource constraints.

• Initial Test: Recommends NT-proBNP as the first-line biomarker for patients with suspected heart failure. A level of ≤400 ng/L is used to rule out heart failure.
• Echocardiography: Urgently requested for all patients with a positive NT-proBNP (>400 ng/L), aiming within 2 weeks.
• Classification: Primarily uses the categories of Heart Failure with reduced Ejection Fraction (HFrEF, LVEF ≤40%), Heart Failure with mildly reduced Ejection Fraction (HFmrEF, LVEF 41-49%), and Heart Failure with preserved Ejection Fraction (HFpEF, LVEF ≥50%).

ESC Approach

The ESC guideline offers a broader, more comprehensive diagnostic algorithm.

• Initial Test: Accepts either BNP, NT-proBNP, or MR-proANP. ESC thresholds are lower: HF is unlikely if BNP <35 pg/mL, NT-proBNP <125 pg/mL.
• Echocardiography: Also the cornerstone of diagnosis but is integrated into a broader HFA-PEFF or H₂FPEF score for HFpEF, which may include advanced imaging and stress testing.
• Classification: Uses the same LVEF categories as NICE but places a stronger emphasis on the new category of HF with improved EF (HFimpEF) (prior LVEF ≤40%, followed by improvement to >40%).

Key Difference & Practical Takeaway

The primary difference lies in the biomarker first-step and thresholds. NICE's UK-focused pathway standardises on NT-proBNP with a higher rule-out threshold (400 ng/L vs 125 pg/mL), reflecting pragmatic use within the NHS. The ESC's lower threshold and use of multiple biomarkers may increase sensitivity. For UK practice, adhering to local NICE-driven pathways is essential for consistency and referral management.

Pharmacological Treatment for Chronic HFrEF

This is the area of most significant alignment, with both guidelines strongly endorsing rapid, sequential, and target-dose titration of four foundational drug classes.

Foundational Therapy: The "Four Pillars"

Both NICE and ESC recommend the following for all HFrEF patients, in the absence of contraindications or intolerability:

• ACE Inhibitor (ACEi) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI): ARNI (sacubitril/valsartan) is preferred over an ACEi for patients who remain symptomatic despite ACEi, beta-blocker, and MRA therapy.
• Beta-Blocker: Bisoprolol, carvedilol, or nebivolol.
• Mineralocorticoid Receptor Antagonist (MRA): Spironolactone or eplerenone.
• SGLT2 Inhibitor (SGLT2i): Dapagliflozin or empagliflozin.

Key Differences in Sequencing and Emphasis

• Initiation & Sequencing:
  • NICE: Traditionally followed a more sequential "start low, go slow" approach. The 2023 update now aligns more closely with the ESC, advocating for quicker, simultaneous initiation. NICE explicitly states to start both an ACEi/ARNI and a beta-blocker within 2 weeks of each other, before symptoms are stable.
  • ESC: Champions a "time-to-therapy" approach, encouraging initiation of all four drug classes as rapidly as possible (within 4 weeks during hospitalisation) and emphasising swift up-titration. The ESC is more assertive in recommending ARNI as a first-line option instead of an ACEi.
• SGLT2 Inhibitors: Both guidelines strongly recommend SGLT2i. NICE positions them after ACEi/ARNI and beta-blocker initiation but notes they can be started early. The ESC often presents them as a foundational pillar to be initiated alongside other therapies.

Practical Takeaway

The historical gap has narrowed. The key message for UK clinicians is to abandon excessive delays in therapy initiation. Start an ACEi/ARNI and a beta-blocker concurrently and add an SGLT2i and MRA as soon as feasible. The ESC's aggressive "time-to-therapy" approach provides a strong evidence-based argument to push for faster optimisation within your local service.

Special Situations

HFmrEF and HFpEF

• NICE: For HFmrEF, considers an ACEi/ARNI and beta-blocker, reflecting the weaker evidence. For HFpEF, treatment focuses on managing comorbidities (e.g., hypertension, AF). SGLT2 inhibitors are recommended for HFpEF to reduce the risk of HF hospitalisation and cardiovascular death.
• ESC: More strongly recommends SGLT2 inhibitors for both HFmrEF and HFpEF. The ESC also provides a more detailed diagnostic framework for HFpEF (HFA-PEFF score).

Iron Deficiency

• NICE: Recommends intravenous ferric carboxymaltose for adults with HFrEF or HFmrEF and iron deficiency (ferritin <100 µg/L or ferritin 100–300 µg/L with transferrin saturation <20%) to improve exercise capacity and symptoms. This is a key update.
• ESC: Similarly recommends IV iron (ferric carboxymaltose) for symptomatic patients with HFrEF/HFmrEF and iron deficiency to improve symptoms and quality of life, and to reduce HF hospitalisations.

Practical Takeaway: There is strong alignment on treating iron deficiency. For HFpEF/HFmrEF, the ESC's stronger endorsement of SGLT2i is becoming standard of care, supported by NICE's positive recommendation.

Practical Clinical Flow for HFrEF in the UK

A synthesis for NHS practice, incorporating both guidelines:

1. Suspicion & Diagnosis: Suspect HF based on symptoms/signs. Check NT-proBNP (per NICE pathway). If >400 ng/L, refer urgently for echocardiogram.
2. Confirm HFrEF (LVEF ≤40%): Initiate ACEi (or consider ARNI) and Beta-blocker concurrently, as soon as possible after diagnosis.
3. Rapid Sequential Addition: Add SGLT2 inhibitor (Dapagliflozin/Empagliflozin) and MRA within weeks, if no contraindications. Check renal function and potassium.
4. Titration: Ambitiously up-titrate all four drug classes to target or maximally tolerated doses within 3-6 months. Monitor blood pressure, renal function, and electrolytes.
5. Advanced Management: For patients who remain symptomatic (NYHA II-IV) despite optimal medical therapy, refer to a specialist heart failure team for consideration of device therapy (ICD/CRT) or advanced options.
6. Comorbidities: Screen for and treat iron deficiency. Manage comorbidities like atrial fibrillation and hypertension.

Frequently Asked Questions (FAQs)

1. Which guideline should I follow in the NHS?

Local NHS Trust policies are often based on NICE, making it the de facto standard for service organisation and funding. However, the ESC guideline represents the international gold standard based on the latest evidence. Clinicians should use the NICE pathway for diagnostic structure and referral, while adopting the ESC's aggressive treatment ethos to optimise patient outcomes within that framework.

2. Is ARNI a first-line treatment?

ESC: Yes, considers ARNI a first-line option instead of an ACEi. NICE: Recommends ARNI for patients who remain symptomatic on an ACEi, beta-blocker, and MRA. However, NICE acknowledges the evidence for first-line use is strong. In practice, for a newly diagnosed, very symptomatic patient, many UK specialists are now considering ARNI first-line, but local formulary approvals may vary.

3. How quickly should I up-titrate medication?

Both guidelines discourage delay. The old model of waiting for "stability" is outdated. Aim for rapid titration—for example, doubling doses every 2-4 weeks if tolerated—with close follow-up. The ESC's "time-to-therapy" goal is a useful benchmark to strive for.

4. Are SGLT2 inhibitors recommended for HFpEF?

Yes. Both NICE and ESC recommend SGLT2 inhibitors for HFpEF to reduce the risk of HF hospitalisation and cardiovascular death. This is a major shift and should be implemented for all HFpEF patients.

5. How do I manage a patient with HF and iron deficiency?

Both guidelines are aligned. Check ferritin and transferrin saturation in symptomatic HFrEF/HFmrEF patients. If iron deficiency is confirmed (ferritin <100 µg/L or ferritin 100–300 µg/L with TSAT <20%), intravenous ferric carboxymaltose is recommended to improve symptoms, functional capacity, and reduce hospitalisations.

Source Links

• NICE Guideline NG106 (Heart failure: diagnosis and management): NICE NG106
• ESC 2023 Guidelines for the diagnosis and treatment of acute and chronic heart failure: ESC guideline: heart failure