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Chronic heart failure

About

What is covered

This pathway covers the diagnosis and management of chronic heart failure in adults (aged 18 or over) in primary and secondary care.
Heart failure is a complex syndrome of symptoms and signs. Untreated it has a poor prognosis, but this can be improved considerably with early and optimal treatment. The most common causes of heart failure in the UK are coronary artery disease and hypertension; many patients have had a myocardial infarction in the past. Patients with heart failure are almost equally divided into those with left ventricular systolic dysfunction and those with preserved ejection fraction. Although the general approach to care is the same whether systolic function is reduced or not, most of the current evidence on drug treatment is for heart failure due to left ventricular systolic dysfunction.

Updates

Updates to this pathway

26 April 2016
  • Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction (NICE technology appraisal guidance 388) added to second-line treatment.
  • Pathway restructured and summarised recommendations replaced with full recommendations.
23 February 2016 Normothermic extracorporeal preservation of hearts for transplantation following donation after brainstem death (NICE interventional procedure guidance 549) added to transplantation.
17 February 2016 Update of chronic heart failure in adults (NICE quality standard 9) added.
15 December 2015 Link to care of dying adults in the last days of life (NICE guideline NG31) added.
24 March 2015 Implantation of a left ventricular assist device for destination therapy in people ineligible for heart transplantation (NICE interventional procedure guidance 516) added to transplantation.
24 June 2014 Implantable cardioverter defibrillators and cardiac resynchronisation therapy for arrhythmias and heart failure (NICE technology appraisal guidance 314) added to implantable devices.
27 August 2013 Insertion and use of implantable pulmonary artery pressure monitors in chronic heart failure (NICE interventional procedure guidance 463) added to monitoring and review.
27 November 2012 Ivabradine for treating chronic heart failure (NICE technology appraisal guidance 267) added to the path on treating heart failure due to left ventricular systolic dysfunction.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on the management of chronic heart failure in adults in primary and secondary care in an interactive flowchart.

What is covered

This pathway covers the diagnosis and management of chronic heart failure in adults (aged 18 or over) in primary and secondary care.
Heart failure is a complex syndrome of symptoms and signs. Untreated it has a poor prognosis, but this can be improved considerably with early and optimal treatment. The most common causes of heart failure in the UK are coronary artery disease and hypertension; many patients have had a myocardial infarction in the past. Patients with heart failure are almost equally divided into those with left ventricular systolic dysfunction and those with preserved ejection fraction. Although the general approach to care is the same whether systolic function is reduced or not, most of the current evidence on drug treatment is for heart failure due to left ventricular systolic dysfunction.

Updates

Updates to this pathway

26 April 2016
  • Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction (NICE technology appraisal guidance 388) added to second-line treatment.
  • Pathway restructured and summarised recommendations replaced with full recommendations.
23 February 2016 Normothermic extracorporeal preservation of hearts for transplantation following donation after brainstem death (NICE interventional procedure guidance 549) added to transplantation.
17 February 2016 Update of chronic heart failure in adults (NICE quality standard 9) added.
15 December 2015 Link to care of dying adults in the last days of life (NICE guideline NG31) added.
24 March 2015 Implantation of a left ventricular assist device for destination therapy in people ineligible for heart transplantation (NICE interventional procedure guidance 516) added to transplantation.
24 June 2014 Implantable cardioverter defibrillators and cardiac resynchronisation therapy for arrhythmias and heart failure (NICE technology appraisal guidance 314) added to implantable devices.
27 August 2013 Insertion and use of implantable pulmonary artery pressure monitors in chronic heart failure (NICE interventional procedure guidance 463) added to monitoring and review.
27 November 2012 Ivabradine for treating chronic heart failure (NICE technology appraisal guidance 267) added to the path on treating heart failure due to left ventricular systolic dysfunction.

Quality standards

Quality statements

Diagnosis by a specialist

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with suspected chronic heart failure who have been referred for diagnosis have an echocardiogram and specialist assessment.

Rationale

To ensure that the correct diagnosis is made, adults with suspected chronic heart failure who have been referred for diagnosis should have an echocardiogram and be seen by a specialist. The specialist should assess the person and review the echocardiogram results. The echocardiogram will show any valve disease and assess the function of the left ventricle. Specialist assessment is needed to confirm the diagnosis of heart failure, consider the possible causes, discuss the appropriate treatment and develop a management plan.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with suspected chronic heart failure referred for diagnosis have an echocardiogram and specialist assessment.
Data source: Local data collection.
Process
Proportion of adults with suspected chronic heart failure referred for diagnosis who have an echocardiogram and specialist assessment.
Numerator – the number in the denominator who have an echocardiogram and specialist assessment.
Denominator – the number of adults with suspected chronic heart failure who are referred for diagnosis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals) ensure that systems are in place so that adults with suspected chronic heart failure who have been referred for diagnosis have an echocardiogram and specialist assessment.
Healthcare professionals (such as doctors and specialists in cardiac care) ensure that adults with suspected chronic heart failure who have been referred for diagnosis have an echocardiogram and specialist assessment. Specialists in cardiac care should assess the person after they have had an echocardiogram.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with suspected chronic heart failure who have been referred for diagnosis have an echocardiogram and specialist assessment.

What the quality statement means for patients, service users and carers

Adults with symptoms of heart failure who have been referred for diagnosis have a test called an echocardiogram to check the structure of their heart and how well it is working. They are then seen by a heart specialist who will carry out an assessment and confirm whether they have chronic heart failure. If chronic heart failure is diagnosed, the specialist will try to find the cause, offer treatment and talk to the person about how to manage their condition.

Source guidance

Chronic heart failure in adults (2010) NICE guideline CG108, recommendations 1.1.1.2 (key priority for implementation), 1.1.1.4 (key priority for implementation), and 1.1.1.5

Definitions of terms used in this quality statement

Echocardiogram
An echocardiogram is a test that uses sound waves to look at the pumping action and structure of the heart, including the heart valves. A probe is moved over the chest and picks up echoes of sound, which are shown as a picture on a screen. In this statement, an echocardiogram refers to a transthoracic Doppler 2D echocardiogram.
[Adapted from Chronic heart failure in adults (NICE guideline CG108) Information for the public].
Suspected chronic heart failure
The most common symptom of chronic heart failure is shortness of breath, either with exercise or at rest. Weight gain and ankle swelling may occur. Fatigue and increased need to pass urine at night are common. A person who has heart failure may wake suddenly from a sound sleep, gasping for breath. Other signs of chronic heart failure can include a cough that won’t go away, nausea, lack of appetite and confusion.
[Adapted from Chronic heart failure in adults (NICE guideline CG108) Information for the public]
Specialist
A doctor 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 (such as GPs and heart failure specialist nurses). The team may involve other services (such as rehabilitation, tertiary care and palliative care) in the care of individual patients.
Specialist assessment or management refers to assessment or management by the specialist multidisciplinary heart failure team. The team will decide on who is the most appropriate team member to address a particular clinical problem.
[Chronic heart failure in adults (NICE guideline CG108)]

Urgent specialist assessment within 2 weeks

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with suspected chronic heart failure and either a previous myocardial infarction (MI) or very high levels of serum natriuretic peptides, who have been referred for diagnosis, have an echocardiogram and specialist assessment within 2 weeks.

Rationale

Adults who have had a previous MI or who have very high levels of serum natriuretic peptides have a higher likelihood of heart failure and a poorer prognosis. The time taken for diagnostic testing and assessment is particularly important for these patients. Having an echocardiogram and specialist assessment within 2 weeks of referral can help to ensure that the person is started on appropriate medication to reduce any further long term damage to the heart.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with suspected chronic heart failure and either a previous MI or very high levels of serum natriuretic peptides, who have been referred for diagnosis, have an echocardiogram and specialist assessment within 2 weeks.
Data source: Local data collection.
Process
Proportion of adults with suspected chronic heart failure and either a previous MI or very high levels of serum natriuretic peptides, who have been referred for diagnosis, who have an echocardiogram and specialist assessment within 2 weeks of referral.
Numerator – the number in the denominator who have an echocardiogram and a specialist assessment within 2 weeks of referral.
Denominator – the number of adults referred for diagnosis with suspected chronic heart failure and either a previous MI or very high levels of serum natriuretic peptides.
Data source: Local data collection.
Outcome
a) Mortality due to heart failure.
Data source: Local data collection.
b) Hospital admissions, inpatient hospital days and readmissions due to heart failure.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals) ensure that systems are in place for adults with suspected chronic heart failure referred for diagnosis to have an echocardiogram and be seen by a specialist within 2 weeks of referral if they have had a previous MI or have very high levels of serum natriuretic peptides.
Healthcare professionals (such as specialists in cardiac care) ensure that adults with suspected chronic heart failure referred for diagnosis have an echocardiogram and are seen within 2 weeks of referral if they have had a previous MI or have very high levels of serum natriuretic peptides.
Commissioners (such as clinical commissioning groups) ensure that they commission services in which adults with suspected chronic heart failure referred for diagnosis have an echocardiogram and are seen by a specialist within 2 weeks of referral if they have had a previous MI or have very high levels of serum natriuretic peptides.

What the quality statement means for patients, service users and carers

Adults with symptoms of chronic heart failure who have been referred for diagnosis have a test called an echocardiogram and are seen by a heart specialist. This should happen within 2 weeks of being referred by their GP if they have had a heart attack in the past or if a blood test shows high levels of a substance (called a ‘serum natriuretic peptide’) that suggests they may have heart failure needing urgent treatment. An echocardiogram is a test to check the structure of their heart and how well it is working. The specialist will carry out an assessment and confirm whether they have chronic heart failure. If chronic heart failure is diagnosed, the specialist will try to find the cause, offer treatment and talk to the person about how to manage the condition.

Source guidance

Chronic heart failure in adults (2010) NICE guideline CG108, recommendations 1.1.1.2 and 1.1.1.4 (key priorities for implementation)

Definitions of terms used in this quality statement

Echocardiogram
An echocardiogram is a test that uses sound waves to look at the pumping action and structure of the heart, including the heart valves. A probe is moved over the chest and picks up echoes of sound, which are shown as a picture on a screen. In this statement, an echocardiogram refers to a transthoracic Doppler 2D echocardiogram.
[Adapted from Chronic heart failure in adults (NICE guideline CG108) Information for the public].
Specialist
A doctor 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 (such as GPs and heart failure specialist nurses). The team may involve other services (such as rehabilitation, tertiary care and palliative care) in the care of individual patients.
Specialist assessment or management refers to assessment or management by this specialist multidisciplinary heart failure team. The team will decide on who is the most appropriate team member to address a particular clinical problem.
[Chronic heart failure in adults (NICE guideline CG108)]
Very high levels of serum natriuretic peptides
Levels of serum natriuretic peptides (B type natriuretic peptide [BNP] and N terminal pro B type natriuretic peptide [NTproBNP]) in the blood are raised in people with heart failure. Very high levels of serum natriuretic peptides are defined as a BNP level above 400 pg/ml or an NTproBNP level above 2000 pg/ml.
[Adapted from Chronic heart failure in adults (NICE guideline CG108), recommendation 1.1.1.4]

Medication for chronic heart failure due to left ventricular systolic dysfunction

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with chronic heart failure due to left ventricular systolic dysfunction are started on low dose angiotensin converting enzyme (ACE) inhibitor and beta blocker medications that are gradually increased until the target or optimal tolerated doses are reached.

Rationale

ACE inhibitors and beta blockers are of proven benefit for people with chronic heart failure due to left ventricular systolic dysfunction, and taking them at the optimum dose will provide the best outcome. However, ACE inhibitors can cause low blood pressure and renal impairment, and beta blockers can initially make heart failure symptoms worse and cause low blood pressure and a low heart rate. Therefore, people taking these medicines should be started on low doses, and the doses gradually increased, with regular checks to monitor any side effects, until the target or optimal tolerated doses are reached.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with chronic heart failure due to left ventricular systolic dysfunction are started on low dose ACE inhibitor and beta blocker medications, which are gradually increased until the target or optimal tolerated doses are reached.
Data source: Local data collection.
Process
a) Proportion of adults diagnosed with chronic heart failure due to left ventricular systolic dysfunction prescribed ACE inhibitor medication who are on a dose that is higher than the starting dose.
Numerator – The number in the denominator who are on a dose of ACE inhibitor medication that is higher than the starting dose.
Denominator – The number of adults diagnosed with chronic heart failure due to left ventricular systolic dysfunction who are prescribed ACE inhibitor medication.
b) Proportion of adults diagnosed with chronic heart failure due to left ventricular systolic dysfunction prescribed beta blocker medication who are on a dose that is higher than the starting dose.
Numerator – The number in the denominator who are on a dose of beta-blocker medication that is higher than the starting dose.
Denominator – The number of adults diagnosed with chronic heart failure due to left ventricular systolic dysfunction who are prescribed beta blocker medication.
Data source: Local data collection.
Outcome
a) Mortality due to heart failure.
Data source: Local data collection.
b) Hospital admissions, inpatient hospital days and readmissions due to heart failure.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, hospitals and community providers) ensure that adults with chronic heart failure due to left ventricular systolic dysfunction are started on low dose ACE inhibitor and beta blocker medications that are gradually increased until the target or optimal tolerated doses are reached, and that there is monitoring for side effects after each increase in dose.
Healthcare professionals (such as GPs, specialists in cardiac care and heart failure specialist nurses) ensure that when they prescribe ACE inhibitors and beta blockers for adults with chronic heart failure due to left ventricular systolic dysfunction, they start with low doses and gradually increase them until the target or optimal tolerated doses are reached. They also ensure that they monitor as a minimum the person’s serum urea, creatinine, electrolytes, eGFR (estimated glomerular filtration rate), heart rate, blood pressure and clinical status after each increase in dose. The multidisciplinary heart failure team will decide on the most appropriate team member to do this, for example, the GP may lead the care in consultation with other members of the team.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with chronic heart failure due to left ventricular systolic dysfunction are started on low dose ACE inhibitor and beta blocker medications that are gradually increased until the target or optimal tolerated doses are reached, and are monitored for side effects after each increase in dose.

What the quality statement means for patients, service users and carers

Adults with chronic heart failure due to left ventricular systolic dysfunction (when the part of the heart that pumps blood around the body isn't squeezing the blood as well as it should) who are prescribed medications for heart failure and high blood pressure (called beta blockers and ACE inhibitors) are given low doses of the medications at first. Doses are then increased gradually until the person is taking the ideal dose for their condition, or the highest dose their body can cope with.

Source guidance

Chronic heart failure in adults (2010) NICE guideline CG108, recommendations 1.2.2.5, 1.2.2.6 and 1.2.2.8

Equality and diversity considerations

ACE inhibitors are less effective in people of African or Caribbean family origin. Healthcare professionals should take this into account and ensure that the person receives additional treatment promptly if needed.

Review after changes in medication

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with chronic heart failure have a review within 2 weeks of any change in the dose or type of their heart failure medication.

Rationale

Medication to treat chronic heart failure can cause significant side effects, including dehydration, low blood pressure, a low heart rate and renal impairment. Some may initially and temporarily make heart failure symptoms worse. When the dose or type of medication for chronic heart failure is changed, the person should have a review within 2 weeks to monitor the effects. This can also include a review of the effectiveness of the medication and whether any further changes or referral to other members of the multidisciplinary team are needed.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with chronic heart failure have a review within 2 weeks of any change in the dose or type of their heart failure medication.
Data source: Local data collection.
Process
Proportion of changes to dose or type of chronic heart failure medication in which the person is reviewed within 2 weeks of a change.
Numerator – the number in the denominator in which the person is reviewed within 2 weeks of the change in medication.
Denominator – the number of changes to dose or type of chronic heart failure medication in adults with chronic heart failure.
Data source: Local data collection.
Outcome
a) Renal impairment.
Data source: Local data collection.
b) Hospital admissions, inpatient hospital days and readmissions.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, hospitals and community providers) ensure that systems are in place so that adults with chronic heart failure have a review within 2 weeks of any change in the dose or type of their heart failure medication.
Healthcare professionals (such as GPs, specialists in cardiac care, heart failure specialist nurses and specialist multidisciplinary heart failure teams) ensure that they carry out a review for adults with chronic heart failure within 2 weeks of any change in the dose or type of their heart failure medication. The multidisciplinary heart failure team will decide who is the most appropriate team member to do this, for example, the GP may lead the care in consultation with other members of the team.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with chronic heart failure have a review within 2 weeks of any change in the dose or type of their heart failure medication.

What the quality statement means for patients, service users and carers

Adults with chronic heart failure are seen by their healthcare professional within 2 weeks of any change in the dose or type of medication they are taking for heart failure, to check for any problems and make sure that the medication is working.

Source guidance

Chronic heart failure in adults (2010) NICE guideline CG108, recommendations 1.4.1.1 and 1.4.1.3

Definitions of terms used in this quality statement

Review when medication is changed
Review should include as a minimum:
  • clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status
  • review of medication, including need for changes and possible side effects
  • blood pressure, serum urea, electrolytes, creatinine and eGFR (estimated glomerular filtration rate).
More detailed monitoring is needed if the person has significant comorbidity or if their condition has deteriorated since the previous review.
[Adapted from Chronic heart failure in adults (NICE guideline CG108), recommendations 1.4.1.1, 1.4.1.2, 1.2.2.6 and 1.2.2.8]

Review of people with stable chronic heart failure

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with stable chronic heart failure have a review of their condition at least every 6 months.

Rationale

Adults with stable chronic heart failure should have a review of their condition at least every 6 months to ensure that their medications are working effectively and they are not experiencing any significant side effects. This will allow their healthcare professional to assess whether there has been any deterioration in their condition, if their medications should be changed, if other procedures (such as cardiac resynchronisation therapy) should be considered and whether referral to another member of the multidisciplinary team is needed.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with stable chronic heart failure have a review of their condition at least every 6 months.
Data source: Local data collection.
Process
Proportion of adults with stable chronic heart failure who have had a review of their condition during the past 6 months.
Numerator – the number in the denominator who have had a review of their condition during the past 6 months.
Denominator – the number of adults with stable chronic heart failure.
Data source: Local data collection.
Outcome
a) Quality of life.
Data source: Local data collection.
b) Renal impairment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, hospitals and community providers) ensure that systems are in place so that adults with stable chronic heart failure have a review of their condition at least every 6 months.
Healthcare professionals (such as GPs and specialist multidisciplinary heart failure team members) ensure that they review adults with stable chronic heart failure at least every 6 months. The multidisciplinary heart failure team will decide on the most appropriate member to do this, for example, the GP may lead care in consultation with other members of the team.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which adults with stable chronic heart failure have a review of their condition at least every 6 months.

What the quality statement means for patients, service users and carers

Adults with chronic heart failure that isn’t worsening are seen at least every 6 months by their healthcare professional, who will check whether their condition has got better or worse, whether their medication needs to be changed and if other types of treatment might be suitable for them. The person may also be referred to other members of the care team, such as a heart failure specialist nurse.

Source guidance

Chronic heart failure in adults (2010) NICE guideline CG108, recommendations 1.4.1.1 and 1.4.1.3

Definitions of terms used in this quality statement

Review of people with stable chronic heart failure
This should include as a minimum:
  • clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status
  • review of medication, including need for changes and possible side effects
  • serum urea, electrolytes, creatinine and eGFR (estimated gromerular filtration rate).
For people taking amiodarone the review should include liver and thyroid function tests, and a review of side effects.
The review should also include a discussion about the suitability of a programme of cardiac rehabilitation.
More detailed monitoring is needed if the person has significant comorbidity or if their condition has deteriorated since the previous review.
[Adapted from Chronic heart failure in adults (NICE guideline CG108), recommendations 1.4.1.1, 1.4.1.2 and 1.2.2.22]
Adults with stable chronic heart failure
Adults diagnosed with chronic heart failure whose clinical condition has not deteriorated, whose heart medication has not been changed and who have not been admitted to hospital because of heart failure.
[Adapted from Chronic heart failure in adults (NICE guideline CG108)]

Programme of cardiac rehabilitation

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.

Quality statement

Adults with stable chronic heart failure are offered an exercise based programme of cardiac rehabilitation.

Rationale

Programmes of cardiac rehabilitation can help to extend and improve the quality of a person’s life through monitored exercise, emotional support and education about lifestyle changes to reduce the risks of further heart problems. They can also reduce uncertainty and anxiety about living with chronic heart failure and, through better management of their condition, the person may have greater opportunities to return to normal activities. Offering an exercise based programme of cardiac rehabilitation to all adults with chronic heart failure when their condition is stable, will help to prevent the person’s heart failure from worsening, reduce their risk of future heart problems and improve their quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with stable chronic heart failure are offered an exercise based programme of cardiac rehabilitation.
Data source: Local data collection.
Process
Proportion of adults diagnosed with stable chronic heart failure who have been referred to an exercise based programme of cardiac rehabilitation.
Numerator – the number in the denominator who have a record of referral to an exercise based programme of cardiac rehabilitation.
Denominator – the number of adults with stable chronic heart failure.
Data source: Local data collection.
Outcome
a) Rates of uptake of and adherence to programmes of cardiac rehabilitation.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from the National Audit of Cardiac Rehabilitation.
b) Patient experience of programmes of cardiac rehabilitation.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from the National Audit of Cardiac Rehabilitation.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community nursing teams and hospitals) ensure that exercise based programmes of cardiac rehabilitation that include a psychological and educational component are available for adults with stable chronic heart failure.
Healthcare professionals (such as GPs, cardiac rehabilitation nurses and specialists in cardiac care) ensure that they offer adults diagnosed with stable chronic heart failure an exercise based programme of cardiac rehabilitation, once they are well enough to attend.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that they commission services in which exercise based cardiac rehabilitation programmes, that include a psychological and educational component, are offered to adults with stable chronic heart failure.

What the quality statement means for patients, service users and carers

Adults with chronic heart failure that isn’t worsening are offered an exercise based programme of cardiac rehabilitation that is designed for people with heart failure, if it is suitable for them and once they are well enough to attend. This programme will include help and support with taking exercise, understanding their condition and how to look after themselves.

Source guidance

Chronic heart failure in adults (2010) NICE guideline CG108, recommendation 1.3.1.1 (key priority for implementation)

Definitions of terms used in this quality statement

Programme of cardiac rehabilitation
This is an exercise based programme of rehabilitation designed for people with heart failure that includes a psychological and educational component.
[Adapted from Chronic heart failure in adults (NICE guideline CG108) recommendation 1.3.1.1]

Equality and diversity considerations

A programme of cardiac rehabilitation should be available for all adults with stable chronic heart failure, including those who may be house bound or in a nursing home. To ensure equality of access to rehabilitation programmes, measures such as providing transport for people to attend sessions and holding the sessions in different locations should be considered. Cardiac rehabilitation should be held in centres that have access for disabled people.
Healthcare professionals should take into account the communication needs of people with stable chronic heart failure, including those with cognitive impairment, when delivering cardiac rehabilitation. All information should be culturally appropriate, and accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People should have access to an interpreter or advocate if needed.

Options for cardiac rehabilitation (developmental)

This quality statement is taken from the chronic heart failure in adults quality standard. The quality standard defines clinical best practice in the treatment of chronic heart failure in adults and should be read in full.
Developmental quality statements set out an emergent area of cutting edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

Adults with chronic heart failure referred to a programme of cardiac rehabilitation are offered sessions during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting.

Rationale

Programmes of cardiac rehabilitation can improve clinical outcomes and quality of life for people with chronic heart failure. People with chronic heart failure are typically older, and may be frail or have comorbidities. This can make it difficult for them to attend group based programmes at hospitals or clinics. Offering programmes of cardiac rehabilitation at different times of day and at different venues is likely to increase both uptake and adherence, and to improve patient experience.

Quality measures

Structure
Evidence of local arrangements to provide programmes of cardiac rehabilitation during and outside working hours, and the choice of undertaking programmes at home, in the community or in a hospital setting.
Data source: Local data collection.
Process
Proportion of people referred to a programme of cardiac rehabilitation who are offered sessions during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting.
Numerator – the number in the denominator offered sessions during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting.
Denominator – the number of adults with chronic heart failure referred to a programme of cardiac rehabilitation.
Data source: Local data collection.
Outcome
a) Rates of uptake of and adherence to programmes of cardiac rehabilitation.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from the National Audit of Cardiac Rehabilitation.
b) Patient experience of programmes of cardiac rehabilitation.
Data source: Local data collection. National data on the uptake of cardiac rehabilitation are available from the National Audit of Cardiac Rehabilitation.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community nursing teams and hospitals) offer programmes of cardiac rehabilitation during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting.
Healthcare professionals (such as GPs, cardiac rehabilitation nurses and specialists in cardiac care) offer adults referred to programmes of cardiac rehabilitation a choice of sessions during and outside working hours, and a choice of undertaking the programme at home, in the community or in a hospital setting.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) commission cardiac rehabilitation services that have the capacity to provide programmes during and outside working hours, and a choice of undertaking the programme at home, in the community or in a hospital setting.

What the quality statement means for patients, service users and carers

Adults with chronic heart failure offered a rehabilitation programme can choose to have their sessions at a time and place that suits them, such as during or outside working hours, and at a hospital or venue in their local area, or at home. This can help people to take part and continue to attend a programme.

Source guidance

Chronic heart failure in adults (2010) NICE guideline CG108, recommendation 1.3.1.1
Cardiac rehabilitation services (2013) NICE commissioning guide

Definitions of terms used in this quality statement

Programme of cardiac rehabilitation
This is an exercise based programme of rehabilitation designed for people with heart failure that includes a psychological and educational component.
[Adapted from Chronic heart failure in adults (NICE guideline CG108) recommendation 1.3.1.1]

Equality and diversity considerations

A programme of cardiac rehabilitation should be available for all adults with chronic heart failure, including those who may be house-bound or in a nursing home. To ensure equality of access to rehabilitation programmes, measures such as providing transport for people to attend sessions and holding the sessions in different locations should be considered. Cardiac rehabilitation should be held in centres that have access for disabled people.
Healthcare professionals should take into account the communication needs of people with chronic heart failure, including those with cognitive impairment, when delivering cardiac rehabilitation. All information should be culturally appropriate, and accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People should have access to an interpreter or advocate if needed.

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Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Monitor serum urea, electrolytes, creatinine and eGFR for signs of renal impairment or hyperkalaemia in patients with heart failure who are taking an ARB.
Refer patients to the specialist multidisciplinary heart failure team for:
  • the initial diagnosis of heart failure and
  • the management of:
    • severe heart failure (NYHA class IV)
    • heart failure that does not respond to treatment
    • heart failure that can no longer be managed effectively in the home setting.

Glossary

angiotensin-converting enzyme
angiotensin II receptor antagonist
angiotensin II receptor antagonists
beats per minute
B-type natriuretic peptide
N-terminal pro-B-type natriuretic peptide
New York Heart Association
The term 'specialist' denotes 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. Unless otherwise specified, specialist assessment or management refers to assessment or management by this specialist multidisciplinary heart failure team. The team will decide who is the most appropriate team member to address a particular clinical problem.

Paths in this pathway

Pathway created: May 2011 Last updated: September 2016

© NICE 2016

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