Chronic heart failure

Short Text

Management of chronic heart failure in adults in primary and secondary care

Introduction

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.

Source guidance

The NICE guidance that was used to create the pathway.
Ivabradine for treating chronic heart failure. NICE technology appraisal guidance 267 (2012)
Cardiac resynchronisation therapy for the treatment of heart failure. NICE technology appraisal guidance 120 (2007)
Implantable cardioverter defibrillators for arrhythmias. NICE technology appraisal guidance 95 (2006)

Quality standards

Quality statements

Urgent referral for people with previous myocardial infarction

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

Quality statement

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

Structure
Evidence of local arrangements to ensure that people presenting in primary care with suspected heart failure and previous myocardial infarction (MI) are referred urgently, to have specialist assessment including echocardiography within 2 weeks.
Process
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.
Numerator – the number of people in the denominator who are referred urgently, to have specialist assessment including echocardiography, with the referral indicating previous MI.
Denominator – the number of people presenting in primary care with suspected heart failure and previous MI.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to refer urgently people with suspected heart failure and previous MI, to have specialist assessment including echocardiography within 2 weeks.
Healthcare professionals ensure they refer urgently people with suspected heart failure and previous MI, to have specialist assessment including echocardiography within 2 weeks.
Commissioners ensure that services refer urgently people with suspected heart failure and previous MI, to have specialist assessment including echocardiography within 2 weeks.
People who go to their GP with symptoms of heart failure and who have had a heart attack in the past are referred urgently for assessment by a heart specialist, including an echocardiogram (a test that uses ultrasound to view the heart), within 2 weeks.

Definitions

  • Echocardiography is defined as transthoracic Doppler 2D echocardiography.
  • 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. Ideally an echocardiogram should be performed at the same time as the specialist assessment.

Source clinical guideline references

NICE clinical guideline 108 recommendation 1.1.1.2 (key priority for implementation)

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 108 audit support, criterion 1.
GP practices collect data on patients with diagnosed heart failure having a confirmation echocardiogram or specialist assessment for QOF HF2 – 'The percentage of patients with a diagnosis of heart failure (diagnosed after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment'. However this data does not examine whether the patient has had a previous MI or was referred urgently.

Measuring serum natriuretic peptides

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

Quality statement

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

Quality measure

Structure
Evidence of local arrangements to ensure serum natriuretic peptide measurement is available in primary care for people presenting with suspected heart failure without previous myocardial infarction (MI).
Process
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.
Numerator – the number of people in the denominator who have their serum natriuretic peptides measured before referral for specialist assessment including echocardiography.
Denominator – the number of people presenting in primary care with suspected heart failure without previous MI.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to measure serum natriuretic peptides in people presenting in primary care with suspected heart failure without previous MI before referral for specialist assessment including echocardiography.
Healthcare professionals ensure they measure serum natriuretic peptides in people presenting in primary care with suspected heart failure without previous MI before making a referral for specialist assessment including echocardiography.
Commissioners ensure serum natriuretic peptide measurement is available to primary care providers.
People who go to their GP with symptoms of heart failure but who haven't had a heart attack in the past are offered a blood test to measure levels of substances in the blood known as serum natriuretic peptides to find out whether they should see a heart specialist.

Definitions

In NICE clinical guideline 108 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.

Source clinical guideline references

NICE clinical guideline 108 recommendation 1.1.1.3 (key priority for implementation)

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 108 audit support, criterion 2.

Two week assessment and diagnosis

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

Quality statement

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

Structure
Evidence of local arrangements to ensure that people referred for specialist assessment including echocardiography, either because of suspected heart failure and previous myocardial infarction (MI) or suspected heart failure and high serum natriuretic peptide levels, are seen by a specialist and have an echocardiogram within 2 weeks of referral.
Process
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.
Numerator – the number of people in the denominator seen by a specialist and having an echocardiogram within 2 weeks of referral.
Denominator – the number 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.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with suspected heart failure and previous MI or suspected heart failure and high serum natriuretic peptide levels to be seen by a specialist and have an echocardiogram within 2 weeks of referral.
Healthcare professionals ensure people referred because of suspected heart failure and previous MI or suspected heart failure and high serum natriuretic peptide levels are seen and have an echocardiogram within 2 weeks of referral.
Commissioners ensure they commission services to provide specialist assessment including echocardiography within 2 weeks of referral for people with suspected heart failure and previous MI or suspected heart failure and high serum natriuretic peptide levels.
People referred urgently to a heart specialist for assessment, including an echocardiogram because of suspected heart failure, who have either had a heart attack in the past or have high levels of serum natriuretic peptides, are seen by a heart specialist and have an echocardiogram within 2 weeks of referral.

Definitions

  • Urgent specialist assessment and echocardiography within 2 weeks is recommended for people with suspected heart failure and
  • a previous MI or
  • high levels of serum natriuretic peptides – B-type natriuretic peptide (BNP) levels above 400 pg/ml (116 pmol/litre) or N-terminal pro-B-type natriuretic peptide (NTproBNP) levels above 2000 pg/ml (236 pmol/litre) in untreated patients. Lower natriuretic peptide thresholds should be considered for patients already on treatment appropriate for heart failure.
  • Echocardiography is defined as transthoracic Doppler 2D echocardiography.
  • 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.
Ideally an echocardiogram should be performed at the same time as the specialist assessment.

Source clinical guideline references

NICE clinical guideline 108 recommendations 1.1.1.2 and 1.1.1.4 (key priorities for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 108 audit support, criterion 3.

Equality and diversity considerations

NICE clinical guideline 108 recommendation 1.1.1.6 advises healthcare practitioners to be aware that:
  • obesity or treatment with diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin II receptor antagonists (ARBs) and aldosterone antagonists can reduce levels of serum natriuretic peptides
  • high levels of serum natriuretic peptides can have causes other than heart failure (for example, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including pulmonary embolism], renal dysfunction [GFR < 60 ml/minute], sepsis, chronic obstructive pulmonary disease [COPD], diabetes, age > 70 years and cirrhosis of the liver).

Six week assessment and diagnosis

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

Quality statement

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

Structure
Evidence of local arrangements to ensure that 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.
Process
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.
Numerator – the number of people in the denominator seen by a specialist and having an echocardiogram within 6 weeks of referral.
Denominator – the number of people referred for specialist assessment including echocardiography because of suspected heart failure and intermediate serum natriuretic peptide levels.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with suspected heart failure and intermediate serum natriuretic peptide levels to be seen by a specialist and have an echocardiogram within 6 weeks of referral.
Healthcare professionals ensure people with suspected heart failure and intermediate serum natriuretic peptide levels are seen by a specialist and have an echocardiogram within 6 weeks of referral.
Commissioners ensure they commission services to provide specialist assessment including echocardiography within 6 weeks of referral for people with suspected heart failure and intermediate serum natriuretic peptide levels.
People referred to a heart specialist for assessment, including an echocardiogram, because of suspected heart failure and raised levels of serum natriuretic peptides, are seen by a heart specialist and have an echocardiogram within 6 weeks.

Definitions

  • Specialist assessment within 6 weeks is recommended for people with suspected heart failure and intermediate levels of serum natriuretic peptides, that is BNP levels between 100 and 400 pg/ml (29-116 pmol/litre) or NTproBNP levels between 400 and 2000 pg/ml (47-236 pmol/litre) in untreated patients. Lower natriuretic peptide thresholds should be considered for patients already on treatment appropriate for heart failure.
  • Echocardiography is defined as transthoracic Doppler 2D echocardiography.
  • 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. Ideally echocardiography should happen at the same time as the specialist assessment.

Source clinical guideline references

NICE clinical guideline 108 recommendation 1.1.1.5.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 108 audit support, criterion 4.

Equality and diversity considerations

NICE clinical guideline 108 recommendation 1.1.1.6 advises healthcare practitioners to be aware that
  • obesity or treatment with diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin II receptor antagonists (ARBs) and aldosterone antagonists can reduce levels of serum natriuretic peptides
  • raised levels of serum natriuretic peptides can have causes other than heart failure (for example, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including pulmonary embolism], renal dysfunction [GFR < 60 ml/minute], sepsis, chronic obstructive pulmonary disease [COPD], diabetes, age > 70 years and cirrhosis of the liver).

Education and self-management

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

Quality statement

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

Structure
Evidence of local arrangements to ensure 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.
Process
a) Proportion of people with chronic heart failure receiving personalised information, education, support and opportunities to discuss their care.
Numerator – the number of people in the denominator receiving personalised information, education, support and opportunities to discuss their care.
Denominator – the number of people with chronic heart failure.
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.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to provide people with chronic heart failure with personalised information, education, support and opportunities for discussion throughout their care and to collect feedback from people with chronic heart failure on their experience of these systems.
Healthcare professionals ensure they offer personalised information, education, support and opportunities for discussion throughout the care of people with chronic heart failure.
Commissioners ensure they commission services that offer personalised information, education, support and opportunities for discussion throughout the care of people with chronic heart failure.
People with chronic heart failure are offered personalised information, education, support and opportunities for discussion throughout their care so they can understand their condition and be involved in its management, if they wish.

Source clinical guideline references

NICE clinical guideline 108 recommendations 1.4.1.4, 1.5.5.2, 1.5.5.3 and 1.5.5.6

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.

Equality and diversity considerations

The information provided should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with chronic heart failure should have access to an interpreter or advocate if needed.

Multidisciplinary heart failure team

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

Quality statement

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

Structure
a) Evidence of a local multidisciplinary heart failure team led by a specialist and consisting of professionals with the appropriate competencies from primary and secondary care.
b) Evidence of local arrangements to ensure people with chronic heart failure are given a single point of contact for the multidisciplinary heart failure team.
Process
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.
Numerator – the number of people in the denominator 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.
Denominator – the number of people with chronic heart failure.
b) Proportion of people with chronic heart failure given a single point of contact for the multidisciplinary heart failure team.
Numerator – the number of people in the denominator given a single point of contact for the multidisciplinary heart failure team.
Denominator – the number of people with chronic heart failure cared for by a multidisciplinary heart failure team.

Description of what the quality statement means for each audience

Service providers ensure the multidisciplinary heart failure team is led by a specialist and consists of professionals with appropriate competencies from primary and secondary care, and that systems are in place to provide those cared for with a single point of contact for the team.
Healthcare professionals ensure that people with chronic heart failure are cared for by a multidisciplinary heart failure team and are given a single point of contact for the team.
Commissioners ensure they commission a multidisciplinary heart failure team led by a specialist and consisting of professionals with appropriate competencies from primary and secondary care.
People with chronic heart failure are cared for by a heart failure team and given a single person to contact from the team.

Definitions

In NICE clinical guideline 108 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, within this quality standard, specialist assessment or management refers to assessment or management by a multidisciplinary heart failure team. The team will decide on the most appropriate member to address a particular clinical problem, which may mean the GP leading the care in consultation with other members of the team.

Source clinical guideline references

NICE clinical guideline 108 recommendation 1.5.3.1 and appendix D – practical notes.

Data source

Structure
a) and b) Local data collection.
Process
a) and b) Local data collection. Access to heart failure liaison services is monitored by the National heart failure audit for people with an unplanned admission to hospital with heart failure.

Treatment with angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists and beta-blockers

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

Quality statement

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 measure

Structure
a) Evidence of local arrangements to ensure that people with chronic heart failure due to left ventricular systolic dysfunction (LVSD) are offered angiotensin-converting enzyme (ACE) inhibitors (or angiotensin II receptor antagonists [ARBs] licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure.
b) Evidence of local arrangements to review people with chronic heart failure due to LVSD after each increase up to the optimal tolerated or target dose of ACE inhibitors (or ARBs) and beta-blockers.
Process
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).
Numerator – the number of people in the denominator prescribed ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors).
Denominator – the number of people with chronic heart failure due to LVSD.
b) Proportion of people with chronic heart failure due to LVSD who are prescribed beta-blockers licensed for heart failure.
Numerator – the number of people in the denominator prescribed beta-blockers licensed for heart failure.
Denominator – the number of people with chronic heart failure due to LVSD.
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.
Numerator – the number of people in the denominator 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.
Denominator – the number of people with chronic heart failure due to LVSD.
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.
Numerator – the number of people in the denominator prescribed ACE inhibitors.
Denominator – the number of people with chronic heart failure due to LVSD prescribed ACE inhibitors or ARBslicensed for heart failure.
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.
Numerator – the number of people in the denominator who reach the optimal tolerated or target dose of ACE inhibitor or ARB.
Denominator – the number of people with chronic heart failure due to LVSD who are prescribed ACE inhibitors or ARBs licensed for heart failure.
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.
Numerator – the number of people in the denominator who reach the optimal tolerated or target dose of beta blocker.
Denominator – the number of people with chronic heart failure due to LVSD who are prescribed beta blockers licensed for heart failure.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to offer ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure to people with chronic heart failure due to LVSD and ensure review after each increase in dose.
Healthcare professionals ensure they offer ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure to people with chronic heart failure due to LVSD and review after each increase in dose.
Commissioners ensure they commission services that offer ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure to people with chronic heart failure due to LVSD and review after each increase in dose.
People with chronic heart failure due to left ventricular systolic dysfunction (when the chamber that pumps blood around the body isn't working as well as it should) are offered drugs called ACE inhibitors and beta-blockers, and their symptoms are reviewed after each increase in dose. People who have intolerable side effects with ACE inhibitors are offered angiotensin II receptor antagonists (ARBs for short) instead of ACE inhibitors.

Source clinical guideline references

NICE clinical guideline 108 recommendations 1.2.2.2 (key priority for implementation), 1.2.2.5, 1.2.2.6, 1.2.2.7 (key priority for implementation) and 1.2.2.8.

Data source

Structure
a) and b) Local data collection.
Process
a) QOF HF3 – 'The percentage of patients with a current diagnosis of heart failure due to LVD who are currently treated with an ACE inhibitor or Angiotensin Receptor Blocker, who can tolerate therapy and for whom there is no contra-indication.'
b) Local data collection.
c) QOF HF4 – 'The percentage of patients with a current diagnosis of heart failure due to LVD who are currently treated with an ACE inhibitor or Angiotensin Receptor Blocker, who are additionally treated with a beta-blocker licensed for heart failure, or recorded as intolerant to or having a contraindication to beta-blockers.' Also contained within NICE clinical guideline 108 audit support, criterion 6.
Prescription of core treatments recommended by NICE guidance is monitored by the National heart failure audit for people with an unplanned admission to hospital with heart failure.
d) Local data collection.
e) Local data collection. Contained within NICE clinical guideline 108 audit support, criterion 7.
f) Local data collection.

Equality and diversity considerations

NICE clinical guideline 108 recommendation 1.2.2.7 promotes equality by highlighting certain groups for whom the provision of beta-blockers has been poor in the past:
Offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including:
  • older adults and
  • patients with:
    • peripheral vascular disease
    • erectile dysfunction
    • diabetes mellitus
    • interstitial pulmonary disease and
    • chronic obstructive pulmonary disease (COPD) without reversibility.

Cardiac rehabilitation programme

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

Quality statement

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 measure

Structure
Evidence of local arrangements to ensure the availability of a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support for people with stable chronic heart failure.
Process
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.
Numerator – the number of people in the denominator attending a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
Denominator – the number of people with stable chronic heart failure and no condition or device that precludes them from exercise-based cardiac rehabilitation.
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.
Numerator – the number of people in the denominator completing a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
Denominator – the number of people with stable chronic heart failure and no condition or device that precludes them from exercise-based cardiac rehabilitation.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with stable chronic heart failure and no precluding condition or device to attend a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
Healthcare professionals ensure people with stable chronic heart failure and no precluding condition are offered a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
Commissioners ensure they commission supervised group exercise-based cardiac rehabilitation programmes for people with chronic heart failure that include education and psychological support.
People with chronic heart failure are offered a supervised group exercise-based rehabilitation programme that includes information and psychological support, if it is suitable for them.

Definitions

The Guideline Development Group for NICE clinical guideline 108 noted that 'the majority of programmes [reviewed in the evidence update] included group exercises which also provided the patients with support and educational opportunities, through formal counselling, as well as iterative learning about their condition and how to cope with it'.
NICE clinical guideline 108 states that the conditions and devices that may preclude an exercise-based rehabilitation programme include:
uncontrolled ventricular response to atrial fibrillation uncontrolled hypertension high-energy pacing devices set to be activated at rates likely to be achieved during exercise. Source clinical guideline references
NICE clinical guideline 108 recommendation 1.3.1.1 (key priority for implementation).

Data source

Structure
Local data collection. Information on exclusion policies and reasons for referral to cardiac rehabilitation programmes is monitored by the National audit of cardiac rehabilitation.
Process
a) and b) Local data collection.

Equality and diversity considerations

Consideration should be given to people with conditions or devices precluding exercise-based programmes. These preclusions may legitimately exclude some people from such rehabilitation programmes.

Monitoring stable chronic heart failure

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

Quality statement

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

Structure
Evidence of local arrangements to ensure 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.
Process
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.
Numerator – the number of people in the denominator receiving a clinical assessment in the last 6 months, including a review of medication and measurement of renal function
Denominator – the number of people with stable chronic heart failure.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for the clinical assessment of people with stable chronic heart failure at least every 6 months, including a review of medication and measurement of renal function.
Healthcare professionals ensure people with stable chronic heart failure have a clinical assessment at least every 6 months, including a review of medication and measurement of renal function.
Commissioners ensure they commission services that provide a clinical assessment for people with stable chronic heart failure at least every 6 months, including a review of medication and measurement of renal function.
People with stable chronic heart failure have a check-up at least every 6 months, including a review of their drug treatment and tests to make sure their kidneys are working properly

Definitions

'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*.
\* This is a minimum. Patients with comorbidities or co-prescribed medications will require further monitoring. Monitoring serum potassium is particularly important if a patient is taking digoxin or an aldosterone antagonist.'
Unless otherwise specified, within this quality standard, specialist assessment or management refers to assessment or management by a multidisciplinary heart failure team. The multidisciplinary heart failure team will decide on the most appropriate member to perform clinical reviews for people with stable chronic heart failure, which may mean the GP leading the care in consultation with other members of the team

Source clinical guideline references

NICE clinical guideline 108 recommendations 1.4.1.1 and 1.4.1.3.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 108 audit support, criterion 17.

Management plans for people admitted to hospital

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

Quality statement

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 measure

Structure
Evidence of local arrangements to ensure that people admitted to hospital because of heart failure have a personalised management plan that is shared with them, their carer(s) and their GP.
Process
a) Proportion of people admitted to hospital because of heart failure who have a personalised management plan when discharged.
Numerator – the number of people in the denominator with a personalised management plan when discharged.
Denominator – the number of people discharged after admission to hospital because of heart failure.
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.
Numerator – the number of people in the denominator who have a personalised management plan shared with them, or their carer(s), when discharged.
Denominator – the number of people discharged after admission to hospital because of heart failure.
c) Proportion of people admitted to hospital because of heart failure whose GP is given their personalised management plan when discharged.
Numerator – the number of people in the denominator whose GP is given their personalised management plan.
Denominator – the number of people discharged after admission to hospital because of heart failure.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to share personalised management plans with people admitted to hospital because of heart failure, their carer(s) and their GP.
Healthcare professionals ensure personalised management plans are shared with people admitted to hospital because of heart failure, their carer(s) and their GP.
Commissioners ensure they commission services that share personalised management plans with people admitted to hospital because of heart failure, their carer(s) and their GP.
People admitted to hospital because of heart failure, their carer(s) and their GP are provided with a copy of their personalised management plan.

Definitions

The management plan should include:
  • how to access advice
  • the main contact in the multidisciplinary heart failure team
  • information on medication
  • information on physical activity
  • information on managing fluid balance
  • details of follow-up appointments.

Source clinical guideline references

NICE clinical guideline 108 recommendation 1.5.2.2.

Data source

Structure
Local data collection.
Process
a), b) and c) Local data collection.

Contribution of multidisciplinary heart failure team to management plans

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

Quality statement

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

Quality measure

Structure
Evidence of local arrangements providing access to a multidisciplinary heart failure team for advice on management plans for people admitted to hospital because of heart failure.
Process
a) Proportion of people admitted to hospital because of heart failure whose management plan includes advice from a multidisciplinary heart failure team.
Numerator – the number of people in the denominator whose management plan includes advice from a multidisciplinary heart failure team.
Denominator – the number of people admitted to hospital because of heart failure.
b) Proportion of people admitted to hospital because of heart failure seen by a specialist in heart failure.
Numerator – the number of people in the denominator seen by a specialist in heart failure.
Denominator – the number of people admitted to hospital because of heart failure.
An audit standard of less than 100% is expected for process b) to account for local service arrangements and appropriate use of resources.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for hospital staff to have access to a multidisciplinary heart failure team for advice on management plans for people admitted to hospital because of heart failure.
Healthcare professionals ensure they contact a multidisciplinary heart failure team for advice on management plans for people admitted to hospital because of heart failure.
Commissioners ensure they commission services that give hospital staff access to a multidiscipliary heart failure team for advice on management plans for people admitted to hospital because of heart failure.
People admitted to hospital because of heart failure receive input from their heart failure team into their management plan.

Definitions

As a minimum, the term 'receive input' should include documented discussion with, or input from a member of, the multidisciplinary heart failure team.
In NICE clinical guideline 108 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, within this quality standard, specialist assessment or management refers to assessment or management by a multidisciplinary heart failure team. The team will decide on the most appropriate member to address a particular clinical problem.

Source clinical guideline references

NICE clinical guideline 108 recommendation 1.4.1.5 (key priority for implementation).

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.

Hospital discharge and follow-up care

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

Quality statement

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

Structure
Evidence of local arrangements to ensure that 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.
Process
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.
Numerator – the number of people in the denominator receiving a clinical assessment by a member of the multidisciplinary heart failure team within 2 weeks of discharge.
Denominator – the number of people discharged following an admission to hospital for heart failure.
Outcome
Re-admissions because of heart failure within 30 days for people with heart failure discharged from hospital following an admission to hospital for heart failure.
Numerator – the number of people in the denominator re-admitted to hospital because of heart failure within 30 days.
Denominator – the number of people discharged following an admission to hospital for heart failure.

Description of what the quality statement means for each audience

Service providers ensure systems are in place so that people admitted to hospital for heart failure are discharged only when they are stable and that they receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.
Healthcare professionals ensure people admitted to hospital for heart failure are discharged only when stable and that they receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.
Commissioners ensure they commission services that discharge people admitted to hospital for heart failure only when they are stable and provide a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.
People admitted to hospital for heart failure leave hospital only when their condition is stable and receive an assessment from a member of the multidisciplinary heart failure team within 2 weeks of leaving hospital.

Definitions

Unless otherwise specified, within this quality standard, specialist assessment or management refers to assessment or management by a multidisciplinary heart failure team. Arrangements for ongoing care will be agreed between the multidisciplinary heart failure team and primary care clinicians.

Source clinical guideline references

NICE clinical guideline 108 recommendation 1.4.1.3 and 1.5.2.1 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection.
Outcome
Local data collection. The admitted patient care commissioning datasets contain the data needed for calculating re-admissions for people admitted to hospital because of heart failure. More information is available at HES Online.
Information on re-admissions is monitored by the National heart failure audit for people who have an unplanned admission to hospital with heart failure.

Specialist and palliative care for people with moderate to severe chronic heart failure

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

Quality statement

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

Structure
a) Evidence of local arrangements to provide people with moderate to severe chronic heart failure, and their carer(s), with access to a specialist in heart failure.
b) Evidence of local arrangements to provide people with moderate to severe chronic heart failure, and their carers(s), with access to a palliative care service.
Process
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.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with moderate to severe chronic heart failure and their carer(s) to have access to a specialist in heart failure and a palliative care service.
Healthcare professionals ensure 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.
Commissioners ensure they commission services providing people with moderate to severe chronic heart failure and their carer(s) with access to a specialist in heart failure and a palliative care service.
People with moderate to severe chronic heart failure and their carer(s) have access to support from a heart specialist and an end of life care (also called palliative care) service.

Definitions

Referrals to the specialist in heart failure or the palliative care service should only be made for appropriate patients who would benefit from the services. Moderate to severe chronic heart failure refers to people with chronic heart failure and moderate to severe symptoms (typically progressive NYHA classes III or IV).
In NICE clinical guideline 108 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.

Source clinical guideline references

NICE clinical guideline 108 recommendations 1.5.1.1, 1.5.9.2 and 1.5.9.3.

Data source

Structure
a) Local data collection.
b) Local data collection. GP practices collect data on the completeness of a palliative care register for QOF PC3 – 'the practice has a complete register available of all patients in need of palliative care/support irrespective of age'. GP practices also collect data on case review meetings for QOF PC2 – 'the practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed'.
Process
a) and b) Local data collection. Information on access to heart failure liaison services and palliative care is an outcome monitored by the National heart failure audit for people with an unplanned admission to hospital with heart failure.

Effective interventions library

Successful effective interventions library details

Implementation

Support for commissioners

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.

Support for education and learning

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.

Pathway information

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.

Information about chronic heart failure

Information about drug treatment

Information about surgery and procedures

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.

Updates to this pathway

27 August 2013 'Insertion and use of implantable pulmonary artery pressure monitors in chronic heart failure' (NICE interventional procedure guidance 463) added to monitoring.
23 July 2013 'Sutureless aortic valve replacement for aortic stenosis' (NICE interventional procedure guidance 456) added to other interventional procedures.
11 January 2013 Minor maintenance updates
27 November 2012 'Ivabradine for treating chronic heart failure' (NICE technology appraisal guidance 267) added to the path on treatment for heart failure due to left ventricular systolic dysfunction.
7 September 2012 Updated guidance on transcatheter aortic valve implantation for aortic stenosis (NICE interventional procedure guidance 421, replaces IPG266) added to the chronic heart failure treatment and monitoring path.
15 June 2012 Minor maintenance updates.
29 May 2012 Minor maintenance updates.
25 October 2011 Minor maintenance updates.

Supporting information

Ensure an integrated approach to care delivered by a multidisciplinary team.
Perform an ECG.
Consider chest X-ray, blood tests (electrolytes, urea and creatinine, eGFR [estimated glomerular filtration rate], thyroid function tests, fasting lipids, fasting glucose, full blood count), urinalysis and peak flow or spirometry.
Monitor serum urea, electrolytes, creatinine and eGFR for signs of renal impairment and hyperkalaemiaFor more information see appendix D of the NICE guideline on chronic heart failure and the NICE guideline on chronic kidney disease .
Be aware that high levels can have causes other than heart failure, including left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia (including pulmonary embolism), GFR less than 60 ml/minute, sepsis, COPD, diabetes, age greater than 70 and liver cirrhosis.

Glossary

Angiotensin-converting enzyme
Beats per minute
BNP > 400 pg/ml (116 pmol/litre) or NTproBNP > 2000 pg/ml (236 pmol/litre)
BNP < 100 pg/ml (29 pmol/litre) or NTproBNP < 400 pg/ml (47 pmol/litre)
New York Heart Association
BNP 100–400 pg/ml (29–116 pmol/litre) or NTproBNP 400–2000 pg/ml (47–236 pmol/litre)
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.

Person with symptoms suggesting heart failure

Person with symptoms suggesting heart failure

Detailed history and clinical examination

Detailed history and clinical examination

Previous MI

Previous MI?

Previous MI

Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks.

Patients without previous MI

Measure serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NTproBNP]) in patients with suspected heart failure without previous MI.

Quality standards

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Source guidance

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Serum natriuretic peptides

Serum natriuretic peptides

Serum natriuretic peptides

Be aware that the level does not differentiate between heart failure due to left ventricular systolic dysfunction and heart failure with preserved ejection fraction.

Quality standards

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Implementation tools

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Source guidance

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High levels of serum natriuretic peptides

High levels of serum natriuretic peptides

High levels of serum natriuretic peptides

Because very high levels of serum natriuretic peptides carry a poor prognosis, refer patients with suspected heart failure and a BNP level above 400 pg/ml (116 pmol/litre) or an NTproBNP level above 2000 pg/ml (236 pmol/litre) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks.
Be aware that high levels can have causes other than heart failure, including left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia (including pulmonary embolism), GFR less than 60 ml/minute, sepsis, COPD, diabetes, age greater than 70 and liver cirrhosis.

Quality standards

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Source guidance

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Raised levels of serum natriuretic peptides

Raised levels of serum natriuretic peptides

Raised levels of serum natriuretic peptides

Refer patients with suspected heart failure and a BNP level between 100 and 400 pg/ml (29–116 pmol/litre) or an NTproBNP level between 400 and 2000 pg/ml (47–236 pmol/litre) to have transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks.
Be aware that high levels can have causes other than heart failure, including left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia (including pulmonary embolism), GFR less than 60 ml/minute, sepsis, COPD, diabetes, age greater than 70 and liver cirrhosis.

Quality standards

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Source guidance

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Specialist assessment and Doppler echocardiography

Specialist assessment and Doppler echocardiography

Specialist assessment and Doppler echocardiography

Echocardiography

Perform transthoracic Doppler 2D echocardiography to exclude important valve disease, assess systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts.
Ensure that:
  • echocardiography is performed on high-resolution equipment by experienced trained operators
  • demand does not compromise quality
  • those reporting echocardiography are experienced in doing so.
When a poor image is produced by transthoracic Doppler 2D echocardiography, consider other imaging methods, such as radionuclide angiography, cardiac magnetic resonance imaging or transoesophageal Doppler 2D echocardiography.

Multidisciplinary approach to care

Ensure an integrated approach to care delivered by a multidisciplinary team.

Quality standards

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Source guidance

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Abnormality consistent with heart failure

Abnormality consistent with heart failure

Further assessment

Further assessment

Further assessment

Assess severity, aetiology, precipitating factors, type of cardiac dysfunction and correctable causes.

Tests for evaluating possible precipitating factors and other diagnoses (if not already carried out)

Perform an ECG.
Consider chest X-ray, blood tests (electrolytes, urea and creatinine, eGFR [estimated glomerular filtration rate], thyroid function tests, fasting lipids, fasting glucose, full blood count), urinalysis and peak flow or spirometry.

Source guidance

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Other cardiac abnormality

Other cardiac abnormality

Heart failure due to LVSD

Heart failure due to left ventricular systolic dysfunction

No clear abnormality

No clear abnormality

Considering serum natriuretic peptides

Consider measuring serum natriuretic peptides if levels not known

Normal levels of serum natriuretic peptides

Normal levels of serum natriuretic peptides

Normal levels of serum natriuretic peptides

Be aware that:
  • BNP < 100 pg/ml (29 pmol/litre) or NTproBNP < 400 pg/ml (47 pmol/litre) in an untreated patient make heart failure unlikely
  • obesity, diuretics, ACE inhibitors, beta-blockers, ARBs and aldosterone antagonists can reduce levels.

Source guidance

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Other diagnosis

Heart failure unlikely, other diagnosis

Other causes of high levels of serum natriuretic peptides

Other causes of high levels of serum natriuretic peptides

Other causes of high levels of serum natriuretic peptides

Be aware that high levels can have causes other than heart failure, including left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia (including pulmonary embolism), GFR less than 60 ml/minute, sepsis, COPD, diabetes, age greater than 70 and liver cirrhosis.

Source guidance

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Investigating other diagnoses

Investigating other diagnoses

Investigating other diagnoses

Tests for evaluating possible precipitating factors and other diagnoses (if not already carried out)

Perform an ECG.
Consider chest X-ray, blood tests (electrolytes, urea and creatinine, eGFR [estimated glomerular filtration rate], thyroid function tests, fasting lipids, fasting glucose, full blood count), urinalysis and peak flow or spirometry.

Source guidance

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HFPEF

Heart failure with preserved ejection fraction

Paths in this pathway

Pathway created: May 2011 Last updated: August 2013

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