Quality statement 3: Medication for chronic heart failure with reduced ejection fraction

Quality statement

Adults with chronic heart failure who have reduced ejection fraction 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. [2011, updated 2016]

Rationale

ACE inhibitors and beta‑blockers are of proven benefit for people with chronic heart failure who have reduced ejection fraction, 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 who have reduced ejection fraction 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 who have reduced ejection fraction 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 who have reduced ejection fraction who are prescribed ACE inhibitor medication.

b) Proportion of adults diagnosed with chronic heart failure who have reduced ejection fraction 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 who have reduced ejection fraction 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 who have reduced ejection fraction 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 who have reduced ejection fraction, 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 who have reduced ejection fraction 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 who have reduced ejection fraction (when the part of the heart that pumps blood around the body isn't squeezing the blood as well as it should) are prescribed medications for heart failure and high blood pressure (called beta blockers and ACE inhibitors). These are given at low doses at first and 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: diagnosis and management (2018) NICE guideline NG106, recommendations 1.4.1, 1.4.3, 1.4.4 and 1.4.13

Definitions of terms used in this quality statement

Heart failure with reduced ejection fraction

Heart failure with an ejection fraction below 40%.

[NICE's guideline on chronic heart failure in adults]

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.