Heart failure: 4 pillars (HFrEF)

Indicator

IND317. 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.

Resource impact

The indicator is intended to replace the following current indicators:

IND193: The percentage of patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, who are currently treated with an ACE-I or ARB.

IND194: The percentage of patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, who are currently treated with a beta-blocker licensed for heart failure.

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.

Table 1 shows the estimated net additional resource impact per 10,000 total population. These are based on a set of assumptions that models the switch of around 70% of people who currently use 2 and 3 pillar treatments to a 4-pillar treatment option. Further details can be found in the resource impact template that accompanies NICE's guideline on chronic heart failure in adults. The template can also be adjusted to amend any of the assumptions used such as the proportion of people with heart failure with reduced ejection fraction (HFrEF).

Titration costs include GP appointment time to initiate treatment and subsequent nurse visits for treatment titration for people switching to 4 pillars of treatment. The capacity impact for an average practice with 10,000 patients is not significant.

Table 1 Estimated total cost per year and change in cost per year to current practice per 10,000 total population

Resource impact - drugs and capacity impacts (HFrEF)	Current practice cost	Future practice cost	Change in cost
Drug costs	£10,400	£17,000	£6,600
Titration costs	£0	£130	£130
Heart failure hospitalisations	£7,500	£4,900	£(2,600)
A&E attendances	£250	£160	£(90)
Adverse events	£12,600	£13,700	£1,100
Total	£30,800	£35,900	£5,100