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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
Scope
Recommendations 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
When to refer to the specialist MDT
Refer patients to the specialist heart failure MDT:

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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
Key priorities for implementation
The areas identified as key priorities for implementation
are:
• Diagnosis
• Treatment
• Rehabilitation
• Monitoring
• Discharge planning
Diagnosis (1)
In patients with symptoms and signs of heart failure:
Measure serum natriuretic peptides in patients without
previous MI
Refer to have transthoracic Doppler 2D echocardiography
and specialist assessment within 2 weeks if
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previous MI
BNP > 400 pg/ml or
NTproBNP > 2000 pg/ml
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
First-line treatment for LVSD
Offer both ACE inhibitors and beta-blockers licensed
for heart failure to all patients with LVSD
Offer beta-blockers licensed for heart failure to all
patients with LVSD, including
• older adults and
• patients with
• peripheral vascular disease
• erectile dysfunction
• diabetes mellitus
• interstitial pulmonary disease
• COPD without reversibility
Second-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 NYHA
class II-III)
• hydralazine in combination with nitrate (especially in
people of African or Caribbean origin with NYHA
class III-IV)
Rehabilitation
Offer a supervised group exercise-based rehabilitation
programme designed for patients with heart failure
• Ensure the patient is stable and does not have
a condition or device that would preclude an
exercise-based rehabilitation programme.
• Include a psychological and educational
component in the programme.
• The programme may be incorporated within
an existing cardiac rehabilitation programme
Monitoring
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
Discharge planning
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 into
account patient and carer wishes, and the level
of care and support that can be provided in the
community.
Costs and savings
per 100,000 population
Recommendations with significant costs
Costs
(£ 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 standards
A 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 measure
a) 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 measure
a) 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 measure
d) 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 measure
a) 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 measure
a) 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 measure
a) 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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