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Chronic heart failure: management of chronic heart failure in adults in primary and secondary care [CG108]

Measuring the use of this guidance

Recommendation: 1.1.1.1

Take a careful and detailed history, and perform a clinical examination and tests to confirm the presence of heart failure

What was measured: Assess with echo or other NICE recommended imaging
Data collection end: March 2011
82%
Data collection end: March 2012
86%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Proportion of patients with heart failure who received an ECG.
Data collection end: March 2015
99.7%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Proportion of patients with heart failure who received an echo.
Data collection end: March 2015
91%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.


Recommendation: 1.1.1.1

Take a careful and detailed history and perform a clinical examination and tests to confirm the presence of heart failure.

What was measured: Proportion of patients with heart failure who received an echo.
Data collection end: March 2014
91%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Proportion of patients with heart failure who received an ECG.
Data collection end: March 2014
99%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.


Recommendation: 1.1.1.2

Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks. [new 2010]

What was measured: Proportion of people referred to a heart failure diagnostic clinic with either a high NTproBNP level or a previous MI who were seen within 2 weeks.
Data collection end: May 2013
86.8%
Area covered: Local
Source: Fazal IA, Bhagra SK, Bailey KM et al. (2015) Impact of using different guideline recommended serum natriuretic peptide thresholds on the diagnosis and referral rates of a diagnostic heart failure clinic. International Journal of Clinical Practice 69: 1349-56

What was measured: Proportion of patients with a diagnosis of heart failure (diagnosed on or after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment 3 months before or 12 months after entering on to the register.
Data collection end: July 2015
90.9%
Area covered: England
Source: Health and Social Care Information Centre. Quality Outcomes Framework.


Recommendation: 1.1.1.4

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. [new 2010]

What was measured: Proportion of people referred to a heart failure diagnostic clinic with either a high NTproBNP level or a previous MI who were seen within 2 weeks.
Data collection end: May 2013
86.8%
Area covered: Local
Source: Fazal IA, Bhagra SK, Bailey KM et al. (2015) Impact of using different guideline recommended serum natriuretic peptide thresholds on the diagnosis and referral rates of a diagnostic heart failure clinic. International Journal of Clinical Practice 69: 1349-56


Recommendation: 1.1.1.7

Transthoracic Doppler 2D echocardiographic examination should be performed to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts.

What was measured: Patients who had an echocardiogram
Data collection end: February 2010
90%
Number that met the criteria: / 50
Area covered: Local
Source: Aktar F (2012) Management of heart failure in a district general hospital, a prospective audit. Circulation. 2012; 125: e743


Recommendation: 1.2.2.2

Offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first.

What was measured: Discharged on ACE inhibitor
Data collection end: March 2010
75%
Data collection end: March 2011
68%
Data collection end: March 2012
72%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Discharged on beta-blocker
Data collection end: March 2010
60%
Data collection end: March 2011
65%
Data collection end: March 2012
78%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Patients that were prescribed a beta blocker
89%
Number that met the criteria: / 282
Area covered: Local multi-site
Source: Pryse-Hawkins H et at (2012) Audit of tertiary heart failure outpatient service to asses compliance with updated NICE guidelines. Heart Vol 98 Suppl1 ppA10-A11

What was measured: Patients that were prescribed an ACEi or ARB
91%
Number that met the criteria: 257 / 282
Area covered: Local multi-site
Source: Pryse-Hawkins H et at (2012) Audit of tertiary heart failure outpatient service to asses compliance with updated NICE guidelines. Heart Vol 98 Suppl1 ppA10-A11

What was measured: LVSD patients discharged on ACE inhibitor after heart surgery
Data collection end: April 2012
33%
Number that met the criteria: / 24
Area covered: Local
Source: Yap K et al (2013) Audit of heart failure management in cardiac surgical patients. International Journal of Surgery, Vol 11, p611

What was measured: LVSD patients discharged on beta-blocker after heart surgery
Data collection end: April 2012
33%
Number that met the criteria: / 24
Area covered: Local
Source: Yap K et al (2013) Audit of heart failure management in cardiac surgical patients. International Journal of Surgery, Vol 11, p611

What was measured: Proportion of patients with heart failure who were prescribed an ACE and/or ARB, beta blocker and mineralocorticoid receptor antagonists (MRA).
Data collection end: March 2014
41%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction who are currently treated with an ACE-I or ARB, the percentage of patients who are additionally currently treated with a beta-blocker licensed for heart failure.
Data collection end: July 2015
76.4%
Area covered: England
Source: Health and Social Care Information Centre. Quality Outcomes Framework.

What was measured: Proportion of patients with heart failure who were prescribed an ACE and/or ARB, beta blocker and mineralocorticoid receptor antagonists (MRA).
Data collection end: March 2015
42%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: The proportion of patients with left ventricular systolic dysfunction prescribed angiotensin-converting-enzymeinhibitor (ACEi) or angiotensin receptor blocker (ARB).
Data collection end: December 2011
86%
Data collection end: December 2014
91%
Area covered: Local
Source: Guha K, Vazir A, Guha K, et al. (2016) Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines Clinical Medicine 16 (5) : 407-411.

What was measured: The proportion of patients with left ventricular systolic dysfunction prescribed a beta blocker.
Data collection end: December 2011
77%
Data collection end: December 2014
89%
Area covered: Local
Source: Guha K, Vazir A, Guha K, et al. (2016) Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines Clinical Medicine 16 (5) : 407-411.


Recommendation: 1.2.2.4

Seek specialist advice and consider adding one of the following if a patient remains symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker: • an aldosterone antagonist licensed for heart failure (especially if the patient has moderate to severe heart failure [NYHA[18] class III–IV] or has had an MI within the past month) or • an angiotensin II receptor antagonist (ARB) licensed for heart failure[19] (especially if the patient has mild to moderate heart failure [NYHA class II–III]) or • hydralazine in combination with nitrate (especially if the patient is of African or Caribbean origin[20] and has moderate to severe heart failure [NYHA class III–IV]) [new 2010]

What was measured: Patients correctly prescribed an aldosterone antagonist
64%
Area covered: Local multi-site
Source: Pryse-Hawkins H et at (2012) Audit of tertiary heart failure outpatient service to asses compliance with updated NICE guidelines. Heart Vol 98 Suppl1 ppA10-A11


Recommendation: 1.2.2.7

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. [new 2010]

What was measured: Proportion of patients with heart failure who were prescribed a beta blocker on discharge for LVSD.
Data collection end: March 2014
85%
Data collection end: March 2015
86%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.


Recommendation: 1.2.2.14

Consider an ARB licensed for heart failure as an alternative to an ACE inhibitor for patients with heart failure due to left ventricular systolic dysfunction who have intolerable side effects with ACE inhibitors

What was measured: Discharged on either ACE inhibitor and / or ARB
Data collection end: March 2011
81%
Data collection end: March 2012
84%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Proportion of patients with heart failure who were prescribed an Angiotensin II receptor antagonists (ARB) on discharge for LVSD.
Data collection end: March 2014
19%
Data collection end: March 2015
19%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Proportion of patients with heart failure who were prescribed an ACE and/or ARB on discharge for LVSD.
Data collection end: March 2014
85%
Data collection end: March 2015
84%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.


Recommendation: 1.2.2.17

Diuretics should be routinely used for the relief of congestive symptoms and fluid retention in patients with heart failure, and titrated (up and down) according to need following the initiation of subsequent heart failure therapies.

What was measured: Those with LVSD discharged on loop diuretic
Data collection end: March 2010
85%
Data collection end: March 2011
86%
Data collection end: March 2012
89%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Those with LVSD discharged on a thiazide diuretic
Data collection end: March 2011
4.3%
Data collection end: March 2012
4%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Patients who required diuretics who were prescribed them
Data collection end: February 2010
100%
Area covered: Local
Source: Aktar F (2012) Management of heart failure in a district general hospital, a prospective audit. Circulation. 2012; 125: e743

What was measured: Proportion of patients with heart failure who were prescribed a loop diuretic on discharge for LVSD.
Data collection end: March 2014
91%
Data collection end: March 2015
92%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Proportion of patients with heart failure who were prescribed a thiazide diuretic on discharge for LVSD.
Data collection end: March 2014
5%
Data collection end: March 2015
6%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.


Recommendation: 1.3.1.1

Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure. Ensure the patient is stable and does not have a condition or device that would preclude an exercise-based rehabilitation programme. Include a psychological and educational component in the programme. The programme may be incorporated within an existing cardiac rehabilitation programme.

What was measured: Patients who were offered cardiac rehabilitation
Data collection end: February 2010
0%
Number that met the criteria: / 50
Area covered: Local
Source: Aktar F (2012) Management of heart failure in a district general hospital, a prospective audit. Circulation. 2012; 125: e743

What was measured: Patients who had their mental state and mood checked
Data collection end: February 2010
2%
Number that met the criteria: 1 / 50
Area covered: Local
Source: Aktar F (2012) Management of heart failure in a district general hospital, a prospective audit. Circulation. 2012; 125: e743

What was measured: Patients who were offered cardiac rehabilitation in first three months of study
15%
Number that met the criteria: 23 / 155
Area covered: Local multi-site
Source: Pryse-Hawkins H et at (2012) Audit of tertiary heart failure outpatient service to asses compliance with updated NICE guidelines. Heart Vol 98 Suppl1 ppA10-A11

What was measured: Patients who were offered cardiac rehabilitation in second three months of study
6%
Number that met the criteria: 8 / 127
Area covered: Local multi-site
Source: Pryse-Hawkins H et at (2012) Audit of tertiary heart failure outpatient service to asses compliance with updated NICE guidelines. Heart Vol 98 Suppl1 ppA10-A11

What was measured: Proportion of patients with chronic heart failure that were referred to a rehabilitation programme.
Data collection end: December 2011
6%
Data collection end: December 2014
3%
Area covered: Local
Source: Guha K, Vazir A, Guha K, et al. (2016) Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines Clinical Medicine 16 (5) : 407-411.


Recommendation: 1.4.1.1

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

What was measured: Proportion of patients with chronic heart failure that had their fluid status monitored at least 6-monthly.
Data collection end: December 2011
90%
Area covered: Local
Source: Guha K, Vazir A, Guha K, et al. (2016) Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines Clinical Medicine 16 (5) : 407-411.

What was measured: Proportion of patients with chronic heart failure that had their functional capacity monitored at least 6-monthly.
Data collection end: December 2011
89%
Area covered: Local
Source: Guha K, Vazir A, Guha K, et al. (2016) Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines Clinical Medicine 16 (5) : 407-411.

What was measured: Proportion of patients with chronic heart failure that had a medication review at least 6-monthly.
Data collection end: December 2011
87%
Area covered: Local
Source: Guha K, Vazir A, Guha K, et al. (2016) Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines Clinical Medicine 16 (5) : 407-411.

What was measured: Proportion of patients with chronic heart failure that had their cardiac rhythm monitored at least 6-monthly.
Data collection end: December 2011
70%
Area covered: Local
Source: Guha K, Vazir A, Guha K, et al. (2016) Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines Clinical Medicine 16 (5) : 407-411.

What was measured: Proportion of patients with chronic heart failure that had their eGFR monitored at least 6-monthly.
Data collection end: December 2011
85%
Area covered: Local
Source: Guha K, Vazir A, Guha K, et al. (2016) Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines Clinical Medicine 16 (5) : 407-411.

What was measured: Proportion of patients with chronic heart failure that had their urea and electrolytes monitored at least 6-monthly.
Data collection end: December 2011
78%
Area covered: Local
Source: Guha K, Vazir A, Guha K, et al. (2016) Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines Clinical Medicine 16 (5) : 407-411.


Recommendation: 1.5.3.1

Heart failure care should be delivered by a multidisciplinary team with an integrated approach across the healthcare community. [2003]

What was measured: Proportion of patients with heart failure who were seen by a member of the heart failure multidisciplinary team (MDT) on their first admission.
Data collection end: March 2014
66%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Proportion of patients with heart failure who were seen by a member of the heart failure multidisciplinary team (MDT) on readmission.
Data collection end: March 2014
68%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Proportion of patients with heart failure who had a follow-up appointment with MDT scheduled within two weeks of discharge.
Data collection end: March 2014
31%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Proportion of patients with heart failure who had a follow-up appointment with MDT scheduled.
Data collection end: March 2014
55%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.


Recommendation: 1.5.9.2

The palliative needs of patients and carers should be identified, assessed and managed at the earliest opportunity

What was measured: Referred to palliative care during first admission in the audit period
Data collection end: March 2010
4%
Data collection end: March 2011
4%
Data collection end: March 2012
3.1%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.

What was measured: Referred to palliative care during a re-admission within the audit period
Data collection end: March 2011
6%
Data collection end: March 2012
7.3%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.


Recommendation: 1.5.9.3

Patients with heart failure and their carers should have access to professionals with palliative care skills within the heart failure team. [2003]

What was measured: Proportion of patients with heart failure who were given a follow-up referral to palliative care.
Data collection end: March 2014
4%
Area covered: National
Source: National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit.



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