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    Consultation on new and updated NICE indicators: GID-IND10330 to GID-IND10335 & GID-IND10337 to GID-IND10338

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    Heart failure: 4 pillars (heart failure with reduced ejection fraction)

    GID-IND10325: The percentage of patients with a current diagnosis of heart failure with reduced ejection fraction, who are currently treated with:

    • an angiotensin-converting enzyme inhibitor or angiotensin receptor-neprilysin inhibitor or angiotensin II receptor blocker

    • a beta blocker

    • a mineralocorticoid receptor antagonist

    • a sodium glucose co-transporter-2 inhibitor.

    Indicator type

    General practice indicator suitable for use in the QOF

    Rationale

    The updated draft NICE guideline for chronic heart failure promotes the four-pillar medication approach (ACE inhibitors, beta-blockers, SGLT2 inhibitors, and MRAs) as first-line treatment for heart failure with reduced ejection fraction. This approach to care is cost-effective and leads to a reduction in cardiovascular-related mortality and hospital admissions.

    The existing QOF prescribing indicators (HF003 and HF006) include people with LVSD or reduced ejection fraction. This draft indicator focuses only on people with reduced ejection fraction, but it is likely that ejection fraction category is under-recorded for the prevalent population. Studies by Bellanca et al (2023), Nakao et al (2023) and Sundaram et al (2022) report a recording of heart failure subtype in general practice between 13% and 26%.

    Testing by NICE in June 2025 of CPRD Aurum suggests:

    • 48% of people with heart failure have LVSD recorded

    • 42% of people with heart failure have an ejection fraction category recorded

    • 13% of people with heart failure have reduced ejection fraction recorded.

    CPRD Aurum March 2025 (Version 2025.03.001) [Data set]. Clinical Practice Research Datalink. https://doi.org/10.48329/6570-ge08.

    Specification

    Numerator: The number of patients in the denominator who are currently treated with:

    • an angiotensin-converting enzyme inhibitor or angiotensin receptor-neprilysin inhibitor or angiotensin II receptor blocker

    • a beta blocker

    • a mineralocorticoid receptor antagonist

    • a sodium glucose co-transporter-2 inhibitor.

    .

    Denominator: The number of patients with a current diagnosis heart failure with reduced ejection fraction.

    Definition: Heart failure with reduced ejection fraction (HFrEF) is a clinical syndrome characterised by a weakened left ventricle, resulting in an ejection fraction of 40% or less.

    Personalised care adjustments or exception reporting should be considered to account for situations where the patient declines, does not attend or has moderate to severe frailty and treatment is inappropriate.

    Question for consultation:

    12. Are there any barriers to prescribing all four recommended drug classes in routine care?

    13. Do stakeholders agree with the focus on people with heart failure and recorded reduced ejection fraction given likely under-recording?

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