Dr Alan Begg discusses the rationale and evidence base for the new indicators for heart failure and the revised indicators for CHD in QOF2

The QOF statistics for 2004/2005 show that in England 95.3% of the available points were achieved for coronary heart disease (CHD).1 The corresponding figure for the left ventricular dysfunction (LVD) subset was 90.3%. There is a national prevalence of 3.6% for CHD and 0.4% for LVD.

The updated indicators

The revised indicators for CHD are shown in Table 1. All the minimum threshold levels have been raised to 40% as there have been high achievement rates in all four countries of the UK and also because the QOF is intended as a tool to encourage the raising of standards.

Table 1: Clinical indicators for coronary heart disease and heart failure
Disease indicator
Clinical indicator
Payment stages
Min (%) Max (%)
The practice can produce a register of CHD patients
% CHD patients with newly diagnosed angina after 1 April 2003 who are referred for exercise testing and/or specialist assessment
% CHD patients with BP recorded in previous 15 months
% CHD patients with BP 150/90 mmHg or less, measured in previous 15 months
% CHD patients who have had their total cholesterol measured in previous 15 months
% CHD patients whose total cholesterol is 5 mmol/l or less, measured in previous 15 months
% CHD patients with a record in previous 15 months that aspirin, an alternative anti-platelet therapy or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded)
CHD 10
% CHD patients on beta-blockers (unless a contraindication or side-effects are recorded)
CHD 11
% CHD patients with a history of myocardial infarction (diagnosed after 1 April 2003) who are currently treated with an ACE inhibitoror angiotensin II antagonist
CHD 12
% CHD patients who have a record of influenza immunisation in the preceding 1 September to 31 March
HF 1
The practice can produce a register of patients with heart failure
HF 2
% patients with heart failure (diagnosed after 1 April 2006) which has been confirmed by echocardiogram or by specialist assessment
HF 3
% CHD patients with heart failure due to LVD who are currently treated with an ACE inhibitor or angiotensin receptor blocker, who can tolerate therapy and for whom there is no contraindication

The maximum level for flu vaccination uptake (CHD 12) has been raised to 90% but the levels for CHD 8, 10 and 11 have been raised to a level lower than 90% and CHD 6 has not been raised at all. The rationale for this is that raising the levels to 90% would have discouraged work on these indicators and because higher levels were felt to be unachievable. The points for the disease registers have been reduced throughout QOF2 with the CHD register (CHD 1) losing two of its six points as the work in maintaining the disease registers is less demanding now that they have been set up.

Smoking indicators

The CHD 3 and CHD 4 indicators along with the smoking indicators from the stroke & TIA, hypertension, diabetes, COPD and asthma sections have been configured into their own category.

Blood pressure targets (CHD 6)

There has been no recent evidence to confirm what the optimum blood pressure should be in patients with established CHD.

The current audit standard of 150/90 mmHg or less remains but the JBS 2 guidelines on the prevention of cardiovascular disease (CVD) recommend that the optimum level of control in all patients with atherosclerotic CVD, which includes patients with CHD should be < 130/80 mmHg.2 The threshold at which treatment should be considered in these patients is systolic blood pressure ? 140 mmHg and/or diastolic BP ? 90 mmHg.

Cholesterol target (CHD 8)

This indicator has been given an extra point to encourage the 10% higher threshold of 70%.

The statin trials have demonstrated a linear relationship between cholesterol reduction and vascular events.3

This benefit has also been seen in the trials which have measured the effects of more intensive cholesterol lowering although the most recent of these, the IDEAL study, did fail to achieve a significant reduction in the primary outcome of major coronary events in patients with a previous myocardial infarction (MI).4

The JBS 2 guidelines recommend the use of a statin in all patients with CHD along with a lower cholesterol target of 4 mmol/l.2

Although QOF2 does not recommend the use of a statin it seems reasonable to prescribe one in all these patients unless it is contraindicated.

By aiming for the lower target of 4 mmol/l, the quality target of 5 mmol/l is more likely to be consistently reached and therefore the indicator points achieved.

Anti-platelet therapy (CHD 9)

Patients with occlusive vascular disease have been shown to benefit from anti-platelet therapy.5 NICE has recently issued clinical and cost effectiveness guidance on the use of clopidogrel in patients with a previous MI who are unable to tolerate aspirin.6

The combined use of clopidogrel and aspirin therapy for up to 1 year after a non-ST-elevation MI is also covered by a recent NICE technology appraisal.7

The benefit of this combined therapy for a mean of 15 days in reducing death, re-infarction and stroke without a significant increase in major bleeding after an acute ST elevation MI has recently been demonstrated in the COMMIT/CC2-2 trial.8

Patients who have been re-vascularised with the insertion of a stent also require dual anti-platelet therapy to reduce the risk of stent thrombosis. This is required for 4 weeks to allow full endothelialisation with a bare metal stent and up to 6 months for a drug eluting stent, depending on the exact type of stent used.

The addition of heart failure indicators

The original QOF indicators covered patients who had a diagnosis of CHD and LVD confirmed by echocardiogram, but this only included about half the patients with heart failure. All patients with suspected heart failure now need to be included in the register (HF 1) – the Read codes for heart failure are listed in Box 1. This inclusion of heart failure is justified on the basis that:

  • it is the only major cardiovascular disease with increasing prevalence
  • it results in impaired quality of life
  • it carries a poor prognosis
  • it is costly to the NHS.

Causes of heart failure other than CHD include:

  • hypertension
  • valvular disease
  • myocarditis
  • thyroid disease
  • alcohol use.

In some cases, such as idiopathic dilated cardiomyopathy, there is no identifiable cause.

Box 1: Heart failure Read codes
Heart failure
Heart Failure NOS
Congestive heart failure
Right ventricular failure
Chronic congestive failure
Decompensated cardiac failure
Compensated cardiac failure
Left ventricular failure
Left ventricular systolic dysfunction
Left ventricular diastolic dysfunction
Acute heart failure
Acute left ventricular failure
Action codes
Cardiological referral
Ultrasound heart scan
Echocardiogram abnormal
Echocardiogram requested
Referral for echocardiogram
Echocardiogram declined
*These codes are currently used in the QOF - it may be necessary to search for the other codes to make the heart failure register complete

Heart failure diagnosis (HF 2)

Patients presenting after 1 April 2006 with suspected heart failure should be investigated primarily to confirm the diagnosis either by echocardiogram, by specialist assessment within secondary care, or by a general practitioner with a specialist interest in heart failure. The patient can only be appropriately managed once the cause of the heart failure has been determined.

Heart failure treatment (HF 3)

Meta-analyses of heart failure trials have demonstrated the benefits of ACE inhibitors in reducing mortality and hospital readmission rates in patients with heart failure.9,10 The use of an angiotensin II receptor blocker in patients with LVD unable to tolerate an ACE inhibitor can lead to a 30% reduction in cardiovascular death or hospitalisation.11

However, it is important to realise that it is possible to have a diagnosis of heart failure which is not due to LVD and this may mean that the patient cohort that needs to be treated under indicator HF3 may be different from those on the heart failure register.

Exception reporting

Although there have been no changes to the rules concerning exception reporting, guidance on the criteria has been restated within the revisions document (Box 2). Practices may have to justify why individual patients or single indicators have been exception coded and the reason should be identifiable on the clinical record.

Box 2: Exception reporting criteria (see www.bma.org.uk)
  • Patients who have been recorded as refusing to attend review who have been invited on at least three occasions during the preceding 12 months
  • Patients for whom it is not appropriate to review the chronic disease parameters due to particular circumstances, e.g. terminal illness, extreme frailty
  • Patients newly diagnosed within the practice or who have recently registered with the practice, who should have measurements made within 3 months and delivery of clinical standards within 9 months, e.g. blood pressure or cholesterol measurements within target levels
  • Patients who are on maximum tolerated doses of medication whose levels remain suboptimal
  • Patients for whom prescribing a medication is not clinically appropriate, e.g. those who have an allergy, another condition or have experienced an adverse reaction
  • Where a patient has not tolerated medication
  • Where a patient does not agree to investigation or treatment (informed dissent), and this has been recorded in their medical records (revisions to the nGMS contract, 2006/2007)
  • Where the patient has a supervening condition which makes treatment of their condition inappropriate, e.g. cholesterol reduction where the patient has liver disease
  • Where an investigative service or secondary care service is unavailable

Structured CHD care

It is still necessary to review CHD patients at least on an annual basis. A recent meta-analysis of the trials on a range of CHD secondary prevention approaches has confirmed the benefits of regular review in reducing morbidity and mortality.12

However, in most of the trials, patients were reviewed more frequently than annually and this needs to be considered if appropriate action is to be taken to address the risk factors and to reach current quality targets.


  1. National Quality and Outcomes Framework Statistics for England 2004/05. www.ic.nhs.uk/services/qof/statisticalbulletin/
  2. JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91(suppl 5): v1-52.
  3. Baigent C,Keech A,Kearney PM et al;Cholesterol Treatment Trialists' (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet 2005; 366(9493): 1267-78.
  4. Pedersen TR, Faergeman O, Kastelein JJ et al; Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) Study Group. High-dose atorvastatin vs usual-dose simvastatin for secondary prevention after myocardial infarction: the IDEAL study: a randomized controlled trial. JAMA 2005; 294(19): 2437-45.
  5. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Br Med J 2002; 324: 71-86.
  6. National Institute for Health and Care Excellence. Vascular disease - clopidogrel and dipyridamole. NICE techology appraisal 90. London: NICE, 2005.
  7. National Institute for Health and Care Excellence. Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome. NICE techology appraisal 80. London: NICE, 2004.
  8. Chen ZM, Jiang LX, Chen YP et al; COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005; 366(9497): 1607-21.
  9. Garg R,Yusuf S.Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA 1995; 273(18): 1450-6.
  10. Flather MD,Yusuf S,Kober L et al. Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group. Lancet 2000; 355(9215): 1575-81.
  11. Granger CB, McMurray JJ,Yusuf S et al; CHARM Investigators and Committees. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial. Lancet 2003; 362(9386): 772-6.
  12. Clark AM,Hartling L,Vandermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med 2005; 143(9): 659-72.

Guidelines in Practice, April 2006, Volume 9(4)
© 2006 MGP Ltd
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