Chronic heart failure

Implementing NICE guidance

2nd. Edition – June 2011

NICE clinical guideline 108

Updated guidance

This guideline is a partial update of NICE clinical guideline 5 (published July 2003) and replaces it

Recommendations have been updated in these areas

•Diagnosis

•Pharmacological treatment

•Monitoring

•Rehabilitation

NICE Pathway

The NICE chronic heart failure pathway covers the diagnosis and management of chronic heart failure in adults in primary and secondary cares

Click here to go to NICE Pathways

website

What this presentation covers

Background

Scope

Multidisciplinary approach to care

When to refer to the specialist MDT

Key priorities for implementation

Costs and savings

Discussion

Find out more

NICE quality standard

Background

Characteristics• Complex syndrome caused by impaired cardiac

function

• Two types: left ventricular systolic dysfunction (LVSD) and heart failure with preserved ejection fraction (HFPEF)

• Most common cause: coronary artery disease

• 30–40% of patients die within a year of diagnosis

Prevalence • Around 900,000 people in the UK

• Expected to rise in the future

ScopeRecommendations in the following areas have been updated in line with evidence published since 2003

Diagnosis – signs, symptoms, serum natriuretic peptides, urgency of referral

Pharmacological treatment for LVSD – ACE inhibitors, beta-blockers, aldosterone antagonists, ARBs, hydralazine in combination with nitrate

Monitoring – serum natriuretic peptides

Rehabilitation – supervised group exercise-based programmes

Multidisciplinary approach to care

Ensure an integrated approach to care delivery by a multidisciplinary team

Specialist

A physician with subspecialty interest in heart failure (often a consultant cardiologist) who leads a specialist multidisciplinary heart failure team of professionals with appropriate competencies from primary and secondary care. The team will involve, where necessary, other services (such as rehabilitation, tertiary care and palliative care) in the care of individual patients

Refer patients to the specialist heart failure MDT:

for the initial diagnosis of heart failure

for the management of severe heart failure (NYHA class IV), heart failure that does not respond to treatment or heart failure that can no longer be managed at home

when they are planning a pregnancy or are pregnant

when they have heart failure due to valve disease

When to refer to the specialist MDT

Key priorities for implementation

The areas identified as key priorities for implementation are:

•Diagnosis

•Treatment

•Rehabilitation

•Monitoring

•Discharge planning

In patients with symptoms and signs of heart failure:

Measure serum natriuretic peptides in patients without previous MI

Refer to have transthoracic Doppler 2D echocardiographyand specialist assessment within 2 weeks if

previous MI

BNP > 400 pg/ml orNTproBNP > 2000 pg/ml

Diagnosis (1)

Diagnosis (2)

Refer to have transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks if:

• BNP 100 – 400 pg/ml or NTproBNP 400 – 2000 pg/ml

If BNP < 100 pg/ml or NTproBNP < 400 pg/ml, heart failure is unlikely in an untreated patient

Offer both ACE inhibitors and beta-blockers licensedfor heart failure to all patients with LVSD

Offer beta-blockers licensed for heart failure to allpatients with LVSD, including•older adults and•patients with•peripheral vascular disease•erectile dysfunction•diabetes mellitus•interstitial pulmonary disease •COPD without reversibility

First-line treatment for LVSD

Seek specialist advice and consider adding one of the following if patient remains symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker:

• aldosterone antagonist licensed for heart failure (especially in NYHA class III–IV or MI in past month)

• ARB licensed for heart failure (especially in NYHAclass II-III)

• hydralazine in combination with nitrate (especially in people of African or Caribbean origin with NYHAclass III-IV)

Second-line treatment for LVSD

Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure

• Ensure the patient is stable and does not havea condition or device that would preclude anexercise-based rehabilitation programme.

• Include a psychological and educationalcomponent in the programme.

• The programme may be incorporated withinan existing cardiac rehabilitation programme

Rehabilitation

All patients with chronic heart failure require monitoring. This monitoring should include:• a clinical assessment of functional capacity, fluid

status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status

• a review of medication, including need for changes and possible side effects

• serum urea, electrolytes, creatinine and eGFR

When a patient is admitted to hospital because of heart failure, seek advice on their management plan from a specialist in heart failure

Monitoring

Patients with heart failure should generally be discharged from hospital only when their clinical condition is stable and the management plan is optimised. Timing of discharge should take intoaccount patient and carer wishes, and the levelof care and support that can be provided in the community.

Discharge planning

Costs and savings per 100,000 population

Recommendations with significant costsCosts (£ per year)

Measuring BNP (or NTproBNP) and subsequent referral 42,000

Monitoring BNP (or NTproBNP) levels 3,000

Supervised cardiac rehabilitation 23,000

Estimated cost of implementation 67,000

Recommendations with significant savings Savings (£ per year)

Reduced hospital admissions 86,000

Estimated saving of implementation 86,000

Discussion• How can we ensure that the appropriate patients

receive transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks?

• How can we ensure that we meet the requirements for BNP/NTproBNP testing?

• How can we guarantee that our discharge systems facilitate discharges in accordance with the recommendations?

• How can we ensure adequate monitoring to prevent readmission?

Heart Improvement

Visit the NHS Improvement heart failure webpage (www.improvement.nhs.uk/heart/heartfailure) for further practical support consistent with implementing the recommendations in this guideline

NHS Evidence

Visit NHS Evidence for the best available evidence on all aspects of cardiovascular disease

Click here to go to the NHS Evidence

website

Find out more

Visit www.nice.org.uk/guidance/CG108 for:•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing report and template•audit support•baseline assessment tool•clinical case scenarios for primary care•online educational tool•shared learning example - BNP testing

NICE Quality Standard

Chronic heart failure

June 2011

Quality standardsA quality standard is a set of specific, concise statements that:

•act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment and prevention

•are derived from the best available evidence such as NICE guidance or other NHS evidence accredited sources

•are produced collaboratively with the NHS and social care, along with their partners and service users

Chronic heart failure quality standard

• Covers assessment, diagnosis and management of chronic heart failure in adults

• Describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for people with chronic heart failure

• Requires services commissioned from and coordinated across all relevant agencies encompassing the whole chronic heart failure care pathway

Quality statement 1

People presenting in primary care with suspected heart failure and previous myocardial infarction are referred urgently, to have specialist assessment including echocardiography within 2 weeks.

Quality measure: Proportion of people presenting in primary care with suspected heart failure and previous MI who are referred urgently, to have specialist assessment including echocardiography, with the referral indicating previous MI.

Quality statement 2

People presenting in primary care with suspected heart failure without previous myocardial infarction have their serum natriuretic peptides measured.

Quality measure: Proportion of people presenting in primary care with suspected heart failure without previous MI who have their serum natriuretic peptides measured before referral for specialist assessment including echocardiography.

Quality statement 3

People referred for specialist assessment including echocardiography, either because of suspected heart failure and previous myocardial infarction or suspected heart failure and high serum natriuretic peptide levels, are seen by a specialist and have an echocardiogram within 2 weeks of referral.

Quality measure: Proportion of people referred for specialist assessment including echocardiography, either because of suspected heart failure and previous MI or suspected heart failure and high serum natriuretic peptide levels, who are seen by a specialist and have an echocardiogram within 2 weeks of referral.

Quality statement 4

People referred for specialist assessment including echocardiography because of suspected heart failure and intermediate serum natriuretic peptide levels are seen by a specialist and have an echocardiogram within 6 weeks of referral.

Quality measure: Proportion of people referred for specialist assessment including echocardiography because of suspected heart failure and intermediate serum natriuretic peptide levels, who are seen by a specialist and have an echocardiogram within 6 weeks of referral

Quality statement 5

People with chronic heart failure are offered personalised information, education, support and opportunities for discussion throughout their care to help them understand their condition and be involved in its management, if they wish.

Quality measure:a) Proportion of people with chronic heart failure receiving personalised

information, education, support and opportunities to discuss their care.

b) Evidence from experience surveys showing that people with chronic heart failure feel they have been provided with personalised information, education, support and opportunities for discussion throughout their care to help them understand their condition and be involved in its management, if they wished.

Quality statement 6

People with chronic heart failure are cared for by a multidisciplinary heart failure team led by a specialist and consisting of professionals with appropriate competencies from primary and secondary care, and are given a single point of contact for the team.

Quality measurea) Proportion of people with chronic heart failure who are cared

for by a multidisciplinary heart failure team led by a specialist and consisting of professionals with the appropriate competencies from primary and secondary care.

b) Proportion of people with chronic heart failure given a single point of contact for the multidisciplinary heart failure team.

Quality statement 7

People with chronic heart failure due to left ventricular systolic dysfunction are offered angiotensin-converting enzyme inhibitors (or angiotensin II receptor antagonists licensed for heart failure if there are intolerable side effects with angiotensin-converting enzyme inhibitors) and beta-blockers licensed for heart failure, which are gradually increased up to the optimal tolerated or target dose with monitoring after each increase.

Quality statement 7: Quality measure

Quality measurea) Proportion of people with chronic heart failure due to

LVSD who are prescribed ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors).

b) Proportion of people with chronic heart failure due to LVSD who are prescribed beta-blockers licensed for heart failure.

c) Proportion of people with chronic heart failure due to LVSD who are prescribed both ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure.

Quality statement 7: Quality measure continued

Quality measured) Proportion of people with chronic heart failure due to

LVSD prescribed either ACE inhibitors or ARBs licensed for heart failure who are prescribed ACE inhibitors.

e) Proportion of people with chronic heart failure due to LVSD who are prescribed ACE inhibitors (or ARBs licensed for heart failure) who reach the optimal tolerated or target dose.

f) Proportion of people with chronic heart failure due to LVSD who are prescribed beta blockers licensed for heart failure who reach the optimal tolerated or target dose.

Quality statement 8

People with stable chronic heart failure and no precluding condition or device are offered a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.

Quality statement 8: quality measure

Quality measure:

a) Proportion of people with stable chronic heart failure and no precluding condition or device who attend a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.

b) Proportion of people with stable chronic heart failure and no precluding condition or device who complete a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.

Quality statement 9

People with stable chronic heart failure receive a clinical assessment at least every 6 months, including a review of medication and measurement of renal function.

Quality measure: Proportion of people with chronic heart failure receiving a clinical assessment in the last 6 months, including a review of medication and measurement of renal function.

Quality statement 10

People admitted to hospital because of heart failure have a personalised management plan that is shared with them, their carer(s) and their GP.

Quality statement 10: Quality measure

Quality measure:a) Proportion of people admitted to hospital because of

heart failure who have a personalised management plan when discharged.

b) Proportion of people admitted to hospital because of heart failure who have a personalised management plan shared with them, or their carer(s), when discharged.

c) Proportion of people admitted to hospital because of heart failure whose GP is given their personalised management plan when discharged.

Quality statement 11

People admitted to hospital because of heart failure receive input to their management plan from a multidisciplinary heart failure team.

Quality measurea) Proportion of people admitted to hospital because of

heart failure whose management plan includes advice from a multidisciplinary heart failure team.

b) Proportion of people admitted to hospital because of heart failure seen by a specialist in heart failure.

Quality statement 12

People admitted to hospital because of heart failure are discharged only when stable and receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.

Quality measurea) Proportion of people admitted to hospital because of

heart failure who receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.

b) Re-admissions for heart failure within 30 days for people with heart failure discharged from hospital.

Quality statement 13

People with moderate to severe chronic heart failure, and their carer(s), have access to a specialist in heart failure and a palliative care service.

Quality measurea) Evidence from experience surveys that people with moderate to severe chronic heart failure, and their carer(s), felt they had access to a specialist in heart failure. b) Evidence from experience surveys that people with moderate to severe chronic heart failure, and their carer(s), felt they had access to a palliative care service.

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1. Petersen S, Rayner M, Wolstenholme J (2002) Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation

2. Cowie MR, Wood DA, Coats AJ et al.(1999) Incidence and aetiology of heart failure; a population-based study. European Heart Journal 20: 421–8

3. Owan TE, Hodge DO, Herges RM et al. (2006) Trends in prevalence and outcome of heart failure with preserved ejection fraction. New England Journal of Medicine 355: 251–9

4. Cowie MR, Wood DA, Coats AJ et al. (2000) Survival of patients with a new diagnosis of heart failure: a population based study. Heart 83: 505–10

5. Hobbs FD, Roalfe AK, Davis RC et al. (2007) Prognosis of all-cause heart failure and borderline left ventricular systolic dysfunction: 5 year mortality follow-up of the Echocardiographic Heart of England Screening Study (ECHOES). European Heart Journal 28: 1128–34

6. Mehta PA, Dubrey SW, McIntyre HF, Walker DM et al. (2009) Improving survival in the 6 months after diagnosis of heart failure in the past decade: population-based data from the UK. Heart 95: 1851–6

7. Stewart S, Horowitz JD (2002) Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 105: 2861–6

8. Petersen S, Rayner M, Wolstenholme J (2002) Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation

References