Heart failure: 4 pillars (HFrEF)
Indicator
The percentage of patients with a current diagnosis of heart failure with reduced ejection fraction, who are currently treated with:
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an angiotensin-converting enzyme inhibitor or angiotensin receptor-neprilysin inhibitor or angiotensin II receptor blocker
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a beta blocker
-
a mineralocorticoid receptor antagonist
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a sodium glucose co-transporter-2 inhibitor.
Indicator type
General practice indicator suitable for use in the Quality and Outcomes Framework.
This document does not represent formal NICE guidance. For a full list of NICE indicators, see our menu of indicators.
To find out how to use indicators and how we develop them, see our NICE indicator process guide.
Rationale
The updated NICE guideline on chronic heart failure in adults 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.
Source guidance
Chronic heart failure in adults: diagnosis and management. NICE guideline NG106 (2018, updated 2025), recommendations 1.4.1 to 1.4.4
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 of heart failure with reduced ejection fraction.
Calculation: Numerator divided by the denominator, multiplied by 100.
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 for each treatment pillar to account for situations where the patient declines or has moderate to severe frailty and treatment is inappropriate.
Expected population size: 0.16% of people in England have a current diagnosis of heart failure with reduced ejection fraction: 16 patients for an average practice with 10,000 patients. CPRD Aurum June 2025 (Version 2025.06.001) [Data set] Medicines and Healthcare products Regulatory Agency.
It is expected that this will increase over time. To be suitable for use in QOF, there should be more than 20 patients eligible for inclusion in the denominator, per average practice with 10,000 patients, prior to application of personalised care adjustments.
ISBN: 978-1-4731-7311-8