Dr Alan Begg explores how NICE’s modified quality standard on chronic heart failure in adults will address priority aspects of care and management

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Read this article to learn more about:

  • changes to national priorities in the assessment, diagnosis, and management of people with chronic heart failure
  • when to refer patients for urgent specialist assessment
  • medication, monitoring, and review.

Key points

Audit points

GP commissioning points

NICE Quality Standard (QS) 9 covers the assessment, diagnosis, and management of chronic heart failure (CHF) in adults aged 18 years and above. It was first published in June 2011 and has recently undergone a substantial update;1 the current update results from the 2014 review of quality standards, which identified that changes were needed to areas for improvement in managing CHF. It included changes to all the 2011 quality statements as well as the addition of two new quality statements, one on review after changes in medication and another on options for cardiac rehabilitation.

Box 1: NICE Pathways

NICE pathways logo

This NICE guidance is part of the NICE Chronic heart failure

The importance of this quality standard

Chronic heart failure is a complex clinical syndrome of symptoms or signs resulting from structural or functional abnormalities of the heart. In CHF onset is not as rapid as in acute HF, which often results in hospitalisation. It suggests that the function of the heart as a pump is impaired and can be classified into the following categories:1

  • left ventricular systolic dysfunction (LVSD) due to reduced left ventricular function
  • heart failure with preserved ejection fraction or
  • a combination of valvular disease, arrhythmias, and ventricular dysfunction.

The most common cause underlying CHF is coronary heart disease (CHD), with most patients having previously had a myocardial infarction.1 The majority of evidence for management is for heart failure due to the first category listed above (i.e. LVSD) as outlined in NICE Clinical Guideline (CG) 108,2 which is the evidence base underpinning this standard.

Why was the quality standard needed?

Patients with CHF have a poor quality of life with the average age of first diagnosis at 76 years.1,2 The prevalence of CHF is expected to rise owing to:1,2

  • an ageing population
  • improved survival of people with CHD
  • more effective treatments for CHF.

The condition has a poor prognosis: 30–40% of people affected die within 1 year of diagnosis,1,2 the mortality thereafter being less than 10% per year.1,2 Based on the prevalence figures from GP heart failure registers, the 5-year survival rate is 58% compared with 93% for the general population.3

NICE QS9 is expected to contribute to improved outcomes in the following areas:1

  • mortality due to CHF
  • hospital admissions
  • ability to manage a long-term condition
  • quality of life
  • medication safety.

NICE updated quality standard on chronic heart failure in adults

The quality statements in NICE QS9, as modified, can be seen in Table 1 (below) and are discussed below. The 2011 statements, although no longer considered national priorities for improvement, may still be used at a local level and are underpinned by current accredited guidance.1 The updating of the quality statements has resulted in a general simplification, which in turn should make their use in day-to-day clinical practice easier.

Table 1: NICE quality standard for chronic heart failure—list of quality statements1
No.Quality statement
1 Adults with suspected chronic heart failure who have been referred for diagnosis have an echocardiogram and specialist assessment. [2011, updated 2016]
2 Adults with suspected chronic heart failure and either a previous myocardial infarction (MI) or very high levels of serum natriuretic peptides, who have been referred for diagnosis, have an echocardiogram and specialist assessment within 2 weeks. [2011, updated 2016].
3 Adults with chronic heart failure due to left ventricular systolic dysfunction 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]
4 Adults with chronic heart failure have a review within 2 weeks of any change in the dose or type of their heart failure medication. [new 2016]
5 Adults with stable chronic heart failure have a review of their condition at least every 6 months. [2011, updated 2016]
6 Adults with stable chronic heart failure are offered an exercise-based programme of cardiac rehabilitation. [2011, updated 2016]
7

(developmental) Adults with chronic heart failure referred to a programme of cardiac rehabilitation are offered sessions during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting. [new 2016]

Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

NICE (2016). Chronic heart failure in adults. Quality Standard 9. NICE, 2011, modified February 2016. Available at: www.nice.org.uk/guidance/qs9
Reproduced with permission

Diagnosis by a specialist—statement 1

The most common symptoms of CHF are outlined in Box 2 (below). Confirmation of a diagnosis of CHF involves performing a transthoracic Doppler 2D echocardiogram followed by specialist assessment (see Figure 1, below).4 This assessment should consider possible causes, discuss appropriate treatment, and develop a management plan.1

Box 2: Symptoms of heart failure1

  • Shortness of breath with exercise or at rest
  • Paroxysmal nocturnal dyspnoea
  • Weight gain and ankle swelling
  • Fatigue and nocturia
  • Persistent cough
  • Nausea and lack of appetite
  • Confusion.
Figure 1: Algorithm summarising recommendations for the diagnosis of heart failure4
Figure 2: Algorithm for the treatment of symptomatic chronic heart failure

MI=myocardial infarction

National Clinical Guideline Centre. Chronic heart failure: the management of chronic heart failure in adults in primary and secondary care. London: National Clinical Guideline Centre, 2010.

Reproduced with permission

Urgent specialist assessment within 2 weeks—statement 2

Statement 2 refers to the need for people suspected of having CHF and who have either a previous MI or very high levels of serum natriuretic peptides (in those without a previous MI) to be seen for echocardiogram and specialist assessment within 2 weeks of referral. Patients in this category have a higher likelihood of heart failure and, because of the poorer prognosis, it is important that they are commenced on appropriate preventative medication as quickly as possible to reduce any further long-term heart damage.

Very high levels of serum natriuretic peptides are:1

  • a B-type natriuretic peptide (BNP) above 400 pg/ml or
  • an N-terminal pro-B-type natriuretic peptide (NTproBNP) above 2000 pg/ml.

Medication for chronic heart failure due to left ventricular systolic dysfunction—statement 3

For those patients with confirmed CHF due to LVSD, taking angiotensin-converting-enzyme (ACE) inhibitors and beta blockers at the optimum dose will provide the best outcome (see Figure 2, below). These medications should be commenced at low doses that are gradually increased until the target or optimum tolerated dose is reached.1 Patients should be monitored regularly for possible side-effects after each increase in dose. Angiotensin converting enzyme inhibitors can cause low blood pressure (BP) and renal impairment. Beta blockers can initially make heart failure symptoms worse as well as causing low BP and low heart rate.1

Monitoring consists (as a minimum) of measuring BP, heart rate, clinical status as well as taking blood for urea, creatinine, electrolytes, and measuring estimated glomerular filtration rate (eGFR). At review, assessment is also needed of functional capacity, fluid status, cognitive status, and nutritional status (see Box 3, below).1,2

Figure 2: Algorithm for the treatment of symptomatic chronic heart failure4
Figure 2: Algorithm for the treatment of symptomatic chronic heart failure

ARB=angiotensin 2 receptor blocker; ACE=angiotensin converting enzyme; ICD=implantable cardioverter-defibrillator; CRT=cardiac resynchronisation therapy

* For more information on drug treatment see appendix D of the NICE guideline and ‘Chronic kidney disease’ (NICE clinical guideline 73).
Consider an ICD in line with ‘Implantable cardiovascular defibrillators for arrhythmias’ (NICE technology appraisal guidance 95).
NYHA class III–IV.
§ Not all ARBs are licensed for use in heart failure in combination with ACE inhibitors.
| NYHA class II–III.
This does not include mixed race. For more information see the full guideline at www.nice.org.uk/guidance/CG108.
** Consider CRT in line with ‘Cardiac resynchronisation therapy for the treatment of heart failure’ (NICE technology appraisal guidance 120)

National Clinical Guideline Centre. Chronic heart failure: the management of chronic heart failure in adults in primary and secondary care. London: National Clinical Guideline Centre, 2010.

Reproduced with permission

Box 3: Review of people with stable chronic heart failure1

As a minimum:

  • Clinical assessment
    • blood pressure
    • cardiac rhythm (pulse assessment)
    • cognitive status
    • functional capacity
    • fluid status
    • nutritional status
  • Review of medication
    • need for changes
    • possible side-effects
  • Biochemistry
    • creatinine
    • electrolytes
    • estimated glomerular filtration rate
    • liver and thyroid function tests if patient is taking amiodarone
    • serum urea
  • Discussion about the suitability of a cardiac rehabilitation programme

Review after changes in medication—statement 4

The timescale for review after any change in dose or type of heart failure medication is 2 weeks, and health professionals and service providers, including GPs, should ensure that systems are in place to make sure this review takes place.1 In addition to performing the checks outlined under statement 3 above, this is also an opportunity to monitor medication effectiveness, the need for any changes, and to consider whether any other multidisciplinary team members should be involved in the patient’s care.

Review of people with stable chronic heart failure—statement 5

NICE defines people with stable chronic heart failure as: ’Adults diagnosed with chronic heart failure whose clinical condition has not deteriorated, whose heart medication has not been changed and who have not been admitted to hospital because of heart failure.’1 In addition to patient review after a change in medication, people with stable CHF should be reviewed every 6 months by an appropriate member of the multidisciplinary team. The review will consider whether there has been any change in their condition, what medication changes may be needed, and the possible need for other suitable treatments or referral to another member of the team. See Box 3, above, for NICE’s stated minimum recommendations for this review.

Programme of cardiac rehabilitation—statement 6

Patients with CHF should be offered a programme of cardiac rehabilitation as it can help to extend and improve their quality of life, giving them a better opportunity to return to normal activities. An exercise-based programme, once the patient’s condition is stable, will help prevent their heart failure from worsening and reduce their risk of future heart problems.1

The exercise-based programme should be designed for patients with stable CHF and include a psychological and educational component; it can be incorporated into an existing cardiac rehabilitation programme.1,2

Options for cardiac rehabilitation (developmental)—statement 7

Statement 7 is an example of a developmental quality statement that sets out a ’cutting-edge’ service or technology currently only found in a minority of providers.1 It involves putting in place significant changes such as a service redesign or new equipment. For patients with CHF, this means offering cardiac rehabilitation at different times of the day including outside of normal working hours, at different venues (at home, in the community, or in a hospital setting), and also offering alternatives to group-based programmes. This approach is likely to increase both uptake and adherence and also to improve the patient experience.

Additional measures, such as providing transport for people to attend sessions to ensure quality of access, should be offered but this will have additional cost implications.

Auditing the standard

To be effective, a quality standard should be based on appropriate evidence (in this case NICE CG1082) and measurable, using data that is ideally collected as part of routine clinical care. NICE gives details of published data in relation to this standard against which performance can be judged.5 One published paper revealed that 80% of people without a previous MI who were referred to a specialist or for an echocardiogram from primary care had had a prior measurement of serum natriuretic peptide.5

In patients with CHF due to LVSD, Quality and Outcomes Framework (QOF) data have shown high levels of uptake of ACE inhibitors or angiotensin 2 receptor blockers (ARBs) (around 98% in 20156), and a rising level in the addition of a beta blocker to ACE inhibitors and ARBs (i.e. from 83% in 20107 to 92% in 20156).

Another source of data, especially if QOF is no longer to continue, is the National Heart Failure Audit compiled by the National Institute for Cardiovascular Outcomes Research.8 The most recent report9 (covering April 2013 to March 2014 and published in November 2015) analysed secondary care data fields, some of which are relevant to the implementation of the updated NICE QS9, but has yet to demonstrate a year-on-year improvement in the use of preventative medication.

Conclusion

Implementation of updated NICE QS9 should in time drive up the quality of care and improve clinical outcomes in patients with CHF, despite the planned changes to QOF and current service challenges; however, without QOF as the basis and measurement of standards in primary care, any improvement may be even harder to achieve.

NICE implementation tools

NICE has developed the following tools to support the implementation of Quality Standard 9 on Chronic heart failure in adults:

  • Commissioning guide
    • services for people with chronic heart failure: guide for commissioners
    • chronic heart failure services: commissioning and benchmarking tool
    • cardiac rehabilitation services: commissioning guide
    • cardiac rehabilitation services: commissioning and benchmarking tool
  • Tailored service improvement support
    • quality standard service improvement template
  • Shared learning
    • shared learning information

Tools to help professionals with implementation and audit can be found in the resources section of QS9.

Key points

  • People with CHF have a poor quality of life and prognosis
  • The prevalence of CHF is expected to rise due to:
    • changing demographics
    • more effective available treatments
    • improved survival
  • NICE updated its 2011 quality standard on CHF in 2016
  • People who are highly likely to have CHF should be referred urgently for echocardiogram and specialist care
  • Individuals with CHF due to LVSD should be prescribed ACE inhibitors and beta blockers at low doses and monitored until the optimum tolerated dose is reached:
    • monitor regularly for side-effects after each increase in dose
  • Practitioners should review after 2 weeks any change in dose or type of heart failure medication
  • People with stable CHF should be reviewed every 6 months by an appropriate member of the multidisciplinary team
  • Individuals with stable CHF should be offered an exercise-based programme of cardiac rehabilitation. This should:
    • include psychological and educational elements
    • be made available and accessible at different times of day, places, and formats to suit individuals and encourage uptake.

CHF=chronic heart failure; LVSD=left ventricular systolic dysfunction;

ACE=angiotensin converting enzyme

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Audit points

  • Statement 1: Proportion of adults with suspected chronic heart failure referred for diagnosis who have an echocardiogram and specialist assessment
  • Statement 2: Proportion of adults with suspected chronic heart failure and either a previous MI or very high levels of serum natriuretic peptides, who have been referred for diagnosis, who have an echocardiogram and specialist assessment within 2 weeks of referral
  • Statement 3: Proportion of adults diagnosed with chronic heart failure due to left ventricular systolic dysfunction prescribed ACE inhibitor medication who are on a dose that is higher than the starting dose bbProportion of adults diagnosed with chronic heart failure due to left ventricular systolic dysfunction prescribed beta‑blocker medication who are on a dose that is higher than the starting dose
  • Statement 4: Proportion of changes to dose or type of chronic heart failure medication in which the person is reviewed within 2 weeks of a change
  • Statement 5: Proportion of adults with stable chronic heart failure who have had a review of their condition during the past 6 months
  • Statement 6: Proportion of adults diagnosed with stable chronic heart failure who have been referred to an exercise‑based programme of cardiac rehabilitation
  • Statement 7: Proportion of people referred to a programme of cardiac rehabilitation who are offered sessions during and outside working hours, and the choice of undertaking the programme at home, in the community or in a hospital setting.

NICE (2016). Chronic heart failure in adults. Quality Standard 9. NICE, 2011, modified February 2016.

Reproduced with permission

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GP commissioning messages

written by Dr David Jenner, GP, Cullompton, Devon

  • CCGs should:
    • use NICE QS9 to conduct a baseline assessment of their local heart failure services and look to mitigate any gaps in service provision
    • commission fast-track (within 2 weeks), consultant-led clinics for people with suspected CHF with previous myocardial infarction or very high serum natriuretic levels, to ensure prompt and accurate diagnosis
    • consider commissioning a specialist heart failure community nursing service to help with the management and regular assessment of patients with CHF
  • A local care pathway, based on NICE QS9, could be used to encourage GPs to perform all the recommended tests before specialist referral
  • Direct access echocardiography is useful for evaluation of murmurs; however, it is not recommended for suspected heart failure without concomitant specialist cardiological assessment
  • PbR tariff costs for a cardiology outpatient: first attendance, £166; follow-up attendance, £96. PbR tariff costs for unbundled services: simple echocardiogram (19 years and over), £67.a

QS=quality standard; CHF=chronic heart failure; PbR=payment by results

awww.england.nhs.uk/resources/pay-syst/tariff-consultation-notice/

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References

  1. NICE. Chronic heart failure in adults. Quality Standard 9. NICE, 2011, modified February 2016. Available at: www.nice.org.uk/qs9
  2. NICE. Chronic heart failure in adults: management. Clinical Guideline 108. NICE, 2010. Available at: www.nice.org.uk/cg108
  3. Cowie M, Wood D, Coats A et al. Survival of patients with a new diagnosis of heart failure: a population based study. Heart 2000; 83: 505–510.
  4. National Clinical Guideline Centre.Chronic heart failure: the management of chronic heart failure in adults in primary and secondary care. London: National Clinical Guideline Centre, 2010. Available at: www. nice.org.uk/guidance/cg108/evidence/ full-guideline-136060525
  5. NICE website. Chronic heart failure [QS9]. Uptake data for this guidance. www.nice.org. uk/guidance/qs9/uptake (accessed 4 April 2016).
  6. QOF database. Heart failure, 2015.www.gpcontract.co.uk/browse/UK/Heart%20Failure/15 (accessed 15 April 2016).
  7. QOF database. Heart failure, 2010.www.gpcontract.co.uk/browse/UK/Heart%20Failure/10 (accessed 15 April 2016).
  8. National Institute for Cardiovascular Outcomes Research. www.ucl.ac.uk/nicor (accessed 4 April 2016).
  9. National Institute for Cardiovascular Outcomes Research, British Society for Heart Failure. National heart failure audit April 2013– March 2014. UCL, NICOR National Heart Failure Audit, 2015. Available at: www.ucl.ac.uk/nicor/audits/heartfailure/reports