1. Implementing NICE guidance
Chronic heart failure
Implementing NICE guidance
This slide set was updated in June 2011 to include the NICE quality standard and NICE Pathway, and to update information content. The NICE Guideline has not changed.
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on chronic heart failure.
This guideline has been written for primary and secondary healthcare professionals who have direct contact with patients with chronic heart failure and make decisions concerning their care.
The guideline is available in a number of formats, including a quick reference guide. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. See the end of the presentation for ordering details.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
The final slide ‘references’ is not for presentation but has been included for information purposes.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
2nd. Edition – June 2011
NICE clinical guideline 108

2. Updated guidance
This guideline is a partial update of NICE clinical guideline 5 (published July 2003) and replaces it
Recommendations have been updated in these areas
Diagnosis
Pharmacological treatment
Monitoring
Rehabilitation
NOTES FOR PRESENTERS:
NICE first published a guideline on chronic heart failure in This has been updated in August The guideline covers diagnosis, treatment, rehabilitation, monitoring and referral and approach to care. Recommendations on diagnosis, pharmacological treatment, monitoring and rehabilitation have been updated in line with new evidence published since All the recommendations in the 2010 guideline are labelled to indicate the year the evidence was last reviewed.
Dating of recommendations
Recommendations are marked as [2003], [2003, amended 2010], [2006], [2007], [2010] or [new 2010].
[2003] indicates that the evidence has not been updated and reviewed since 2003
[2003, amended 2010] indicates that the evidence has not been updated and reviewed since 2003 but a small amendment has been made to the recommendation
[2006] applies to guidance from NICE technology appraisal 95, published in 2006
[2007] applies to two recommendations from ‘MI: secondary prevention’ (NICE clinical guideline 48) and guidance from NICE technology appraisal 120, both published in 2007
[2010] indicates that the evidence has been reviewed but no changes have been made to the recommendation
[new 2010] indicates that the evidence has been reviewed and the recommendation has been updated or added

3. Click here to go to NICE Pathways website
The NICE chronic heart failure pathway covers the diagnosis and management of chronic heart failure in adults in primary and secondary cares
NOTES FOR PRESENTERS:
Key points to raise
If you are showing this presentation when connected to the internet, click on the orange button to go straight to the NICE Pathways website. The front page includes a two minute video giving an overview of the features and content within the site, as well as the list of topics covered.
NICE Pathways: guidance at your fingertips
Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.
The NICE pathway can be found at
Click here to go to NICE Pathways website

4. What this presentation covers
Background
Scope
Multidisciplinary approach to care
When to refer to the specialist MDT
Key priorities for implementation
Costs and savings
Discussion
Find out more
NICE quality standard
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guideline and why it is important.
We will then present the concept of multidisciplinary care and when to refer to the specialist MDT followed key priorities for implementation. The NICE guideline contains ten key priorities for implementation, which are marked with KPI in the quick reference guide (QRG). The key priorities for implementation cover the following areas:
Diagnosis
Treatment
Rehabilitation
Monitoring
Discharge planning
We will also present recommendations which are related to the key priorities for implementation and will highlight when patients should be referred to the specialist multidisciplinary heart failure team.
Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline.
Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Finally, we will end the presentation on the guideline with further information about the support provided by NICE and NHS improvement.
Slides are also provided which summarise the NICE Quality Standard

5. Background Characteristics
Complex syndrome caused by impaired cardiac function
Two types: left ventricular systolic dysfunction (LVSD) and heart failure with preserved ejection fraction (HFPEF)
Most common cause: coronary artery disease
30–40% of patients die within a year of diagnosis
Prevalence
Around 900,000 people in the UK
Expected to rise in the future
NOTES FOR PRESENTERS:
Key points to raise:
Heart failure is a complex clinical syndrome of symptoms and signs that suggest the efficiency of the heart as a pump is impaired. It is caused by structural or functional abnormalities of the heart. Some patients have heart failure due to left ventricular systolic dysfunction (LVSD) This is caused by impaired left ventricular contraction, and is usually characterised by a reduced left ventricular ejection fraction. Others have heart failure with a preserved ejection fraction (HFPEF). This is usually associated with impaired left ventricular relaxation, rather than left ventricular contraction, and is characterised by a normal or preserved left ventricular ejection fraction.
The most common cause of heart failure in the UK is coronary artery disease, and many patients have had a myocardial infarction in the past.
Around 900,000 people in the UK have heart failure. Almost as many have damaged hearts but, as yet, no symptoms of heart failure1. Both the incidence and prevalence of heart failure increase steeply with age2, as a result the prevalence of heart failure is expected to rise in future, with the ageing population3.
Heart failure has a poor prognosis: 30–40% of patients diagnosed with heart failure die within a year – but thereafter the mortality is less than 10% per year, and there is evidence of a trend of improved prognosis in the past 10 years4,5,6.
On average, a GP will look after 30 patients with heart failure, and suspect a new diagnosis of heart failure in perhaps 10 patients annually7. Heart failure accounts for a total of 1 million inpatient bed days – 2% of all NHS inpatient bed-days – and 5% of all emergency medical admissions to hospital. Hospital admissions because of heart failure are projected to rise by 50% over the next 25 years – largely as a result of the ageing population7,8,.
It is clear that heart failure has an adverse effect on patients’ quality of life and can place a financial burden upon carers, patients and health service providers. It is important that these patients receive the highest quality of care in order to minimise these negative effects.
For references please see final slide

6. Scope
Recommendations in the following areas have been updated in line with evidence published since 2003
Diagnosis – signs, symptoms, serum natriuretic peptides, urgency of referral
Pharmacological treatment for LVSD – ACE inhibitors, beta-blockers, aldosterone antagonists, ARBs, hydralazine in combination with nitrate
Monitoring – serum natriuretic peptides
Rehabilitation – supervised group exercise-based programmes
NOTES FOR PRESENTERS:
Key points to raise:
Recommendations on diagnosis, pharmacological treatment, monitoring and rehabilitation have been updated in line with new evidence published since 2003.
Groups covered
Adults with symptoms or a diagnosis of chronic heart failure.
Groups not covered
Patients with right heart failure as a consequence of respiratory disease.
Topics covered by the partial update are:
Diagnosis: symptoms and signs, use of serum natriuretic peptides (BNP or NTproBNP).
Pharmacological treatment for heart failure due to LVSD: angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, aldosterone antagonists, angiotensin II receptor antagonists (ARBs), and hydralazine in combination with nitrates.
Monitoring: measurement of serum natriuretic peptides.
Cardiac rehabilitation: supervised group exercise-based rehabilitation programmes which include psychological and educational components.  

7. Multidisciplinary approach to care
Ensure an integrated approach to care delivery by a multidisciplinary team Specialist A physician with subspecialty interest in heart failure (often a consultant cardiologist) who leads a specialist multidisciplinary heart failure team of professionals with appropriate competencies from primary and secondary care. The team will involve, where necessary, other services (such as rehabilitation, tertiary care and palliative care) in the care of individual patients
NOTES FOR PRESENTERS:
Key points to raise:
Specialist
Throughout this guideline, the term ‘specialist’ denotes a physician with subspecialty interest in heart failure (often a consultant cardiologist) who leads a specialist multidisciplinary heart failure team of professionals with appropriate competencies from primary and secondary care. The team will involve, where necessary, other services (such as rehabilitation, tertiary care and palliative care) in the care of individual patients.
Unless otherwise specified, within this guideline specialist assessment or management refers to assessment or management by this specialist multidisciplinary heart failure team. The team will decide who is the most appropriate team member to address a particular clinical problem.

8. When to refer to the specialist MDT
Refer patients to the specialist heart failure MDT:
for the initial diagnosis of heart failure
for the management of severe heart failure (NYHA class IV), heart failure that does not respond to treatment or heart failure that can no longer be managed at home
when they are planning a pregnancy or are pregnant
when they have heart failure due to valve disease

NOTES FOR PRESENTERS:
These are NOT key priorities for implementation, but have been included to highlight when patients should be referred to the specialist multidisciplinary heart failure team
Key points to raise:
Refer patients to the specialist multidisciplinary (MDT) heart failure team for:
the initial diagnosis of heart failure and
the management of:
severe heart failure (NYHA class IV)
heart failure that does not respond to treatment
heart failure that can no longer be managed effectively in the home setting. [new 2010] [ ]
In women of reproductive age who have heart failure, contraception and pregnancy should be discussed. If pregnancy is being considered or occurs, specialist advice should be sought. Subsequently, specialist care should be shared between the cardiologist and obstetrician. [2003] [ ]
Patients with heart failure due to valve disease should be referred for specialist assessment and advice regarding follow-up. [2003] [ ]
See page 4 of the quick reference guide and slide 17 for more information about the involvement of the specialist multidisciplinary team in the diagnosis of chronic heart failure.
Additional information:
Related recommendation: When a patient is admitted to hospital because of heart failure, seek advice on their management plan from a specialist in heart failure. [ ]
Some patients may also require referral to the specialist multidisciplinary heart failure team for consideration of invasive procedures such as cardiac transplantation, cardiac resynchronisation therapy (in line with NICE technology appraisal guidance 120 [2007] or implantable cardioverter defibrillators (in line with NICE technology appraisal guidance 95 [2006]).
Please refer to the NICE website for updates on the review status of these appraisals.

9. Key priorities for implementation
The areas identified as key priorities for implementation are:
Diagnosis
Treatment
Rehabilitation
Monitoring
Discharge planning
NOTES FOR PRESENTERS:
The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. These cover updated and original recommendations which remain priorities. They are divided into five areas of key priority and within these there are ten recommendations that we will consider in turn. Where appropriate we will also present the related subcategories of recommendations and individual recommendations within the guideline in order to ensure the full scope of the guideline is presented

10.  Diagnosis (1) In patients with symptoms and signs of heart failure:
Measure serum natriuretic peptides in patients without previous MI
Refer to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks if
previous MI
BNP > 400 pg/ml or NTproBNP > 2000 pg/ml 
NOTES FOR PRESENTERS:
Key points to raise:
Measure serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NTproBNP]) in patients with suspected heart failure without previous MI. [new 2010] [ ]
Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks. [new 2010] [ ]
Because very high levels of serum natriuretic peptides carry a poor prognosis, refer patients with suspected heart failure and a BNP level above 400 pg/ml (116 pmol/litre) or an NTproBNP level above 2000 pg/ml (236 pmol/litre) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks. [new 2010] [ ]
Related recommendations:
Consider a serum natriuretic peptide test (if not already performed) when heart failure is still suspected after transthoracic Doppler 2D echocardiography has shown a preserved left ventricular ejection fraction. [ ]
There are further recommendations specifically about transthoracic Doppler 2D echocardiography [ , , ]. These are the same as in the 2003 guideline.
The following recommendations identify the need to be aware when measuring serum natriuretic peptides.
Be aware that:
obesity or treatment with diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin II receptor antagonists (ARBs) and aldosterone antagonists can reduce levels of serum natriuretic peptides
high levels of serum natriuretic peptides can have a cause other than heart failure (for example, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including pulmonary embolism], renal dysfunction [GFR  60 ml/minute], sepsis, chronic obstructive pulmonary disease [COPD], diabetes, age  70 years and cirrhosis of the liver). [new 2010] [ ]
For more information about all the recommendations for the diagnosis of chronic heart failure see pages 4 and 5 of the quick reference guide and slide 17

11. Diagnosis (2)
Refer to have transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks if:
BNP 100 – 400 pg/ml or NTproBNP 400 – 2000 pg/ml
If BNP < 100 pg/ml or NTproBNP < 400 pg/ml, heart failure is unlikely in an untreated patient
NOTES FOR PRESENTERS:
These are NOT key priorities for implementation, but have been included to highlight other recommendations that should be considered when making a diagnosis.
Key points to raise:
Refer patients with suspected heart failure and a BNP level between 100 and 400 pg/ml (29–116 pmol/litre) or an NTproBNP level between 400 and 2000 pg/ml (47–236 pmol/litre) to have transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks. [new 2010] [ ]
Be aware that:
a serum BNP level less than 100 pg/ml (29 pmol/litre) or an NTproBNP level less than 400 pg/ml (47 pmol/litre) in an untreated patient makes a diagnosis of heart failure unlikely
the level of serum natriuretic peptide does not differentiate between heart failure due to left ventricular systolic dysfunction and heart failure with preserved left ventricular ejection fraction. [new 2010] [ ]

12. First-line treatment for LVSD
Offer both ACE inhibitors and beta-blockers licensed for heart failure to all patients with LVSD
Offer beta-blockers licensed for heart failure to all patients with LVSD, including
older adults and
patients with
peripheral vascular disease
erectile dysfunction
diabetes mellitus
interstitial pulmonary disease
COPD without reversibility
NOTES FOR PRESENTERS:
Key points to raise:
Offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first. [new 2010] [ ]
Offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including older adults and patients with: peripheral vascular disease, erectile dysfunction, diabetes, mellitus, interstitial pulmonary disease and chronic obstructive pulmonary disease (COPD) without reversibility. [new 2010] [ ]
Additional information: The following recommendations are related
Start ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target dose is achieved. [2010] [ ]
Measure serum urea, creatinine, electrolytes and eGFR at initiation of an ACE inhibitor and after each dose increment1.  [2010] [ ]
 Introduce beta-blockers in a ‘start low, go slow’ manner, and assess heart rate, blood pressure, and clinical status after each titration. [2010] [ ]
Switch stable patients who are already taking a beta-blocker for a comorbidity (for example, angina or hypertension), and who develop heart failure due to left ventricular systolic dysfunction, to a beta-blocker licensed for heart failure. [new 2010] [ ]
There are also two recommendations about alternative first-line treatment for patients who are intolerant of ACE inhibitors.
Consider an ARB licensed for heart failure as an alternative to an ACE inhibitor for patients with heart failure due to left ventricular systolic dysfunction who have intolerable side effects with ACE inhibitors. [new 2010] [ ]. See recommendation relating to the monitoring of patients with heart failure who are taking an ARB
Seek specialist advice and consider hydralazine in combination with nitrate for patients with heart failure due to left ventricular systolic dysfunction who are intolerant of ACE inhibitors and ARBs [new 2010] [ ]
For more information about the first-line treatment of heart failure due to LVSD see pages 6 and 7 of the quick reference guide and slide 18
Footnote
 1. For practical recommendations on treatment with ACE inhibitors see ‘Chronic kidney disease’ (NICE clinical guideline 73).

13. Second-line treatment for LVSD
Seek specialist advice and consider adding one of the following if patient remains symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker:
aldosterone antagonist licensed for heart failure (especially in NYHA class III–IV or MI in past month)
ARB licensed for heart failure (especially in NYHA class II-III)
hydralazine in combination with nitrate (especially in people of African or Caribbean origin with NYHA class III-IV)
NOTES FOR PRESENTERS:
Key points to raise:
This key priority is a new recommendation and represents a change in practice. The recommendation is based on evidence of better outcomes for particular second-line treatments in certain subgroups.
The recommendation is given in full below.
Seek specialist advice and consider adding one of the following if a patient remains symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker:
an aldosterone antagonist licensed for heart failure (especially if the patient has moderate to severe heart failure [NYHA 1 class III–IV] or has had an MI within the past month)
an angiotensin II receptor antagonist (ARB) licensed for heart failure2 (especially if the patient has mild to moderate heart failure [NYHA class II–III]) or
hydralazine in combination with nitrate (especially if the patient is of African or Caribbean origin3 and has moderate to severe heart failure [NYHA class III–IV]) [new 2010] [ ]
Additional information:
The following recommendation is also related to the second-line treatment of heart failure due to left ventricular systolic dysfunction.
Seek specialist advice before offering second-line treatment to patients with heart failure due to left ventricular systolic dysfunction. [new 2010] [ ]
Recommendations , , and are also about the use of second-line treatments for heart failure due to LVSD. For more information about these recommendations see the NICE guideline.
For more information about the second-line treatment of heart failure due to LVSD see pages 6 and 7 of the quick reference guide and slide 18
Footnote
1. New York Heart Association Classification of heart failure
2. Not all ARBs are licensed for use in heart failure in combination with ACE inhibitors
3. This does not include mixed race. For more information see the full guideline

14. Rehabilitation
Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure
Ensure the patient is stable and does not have a condition or device that would preclude an exercise-based rehabilitation programme.
Include a psychological and educational component in the programme.
The programme may be incorporated within an existing cardiac rehabilitation programme
NOTES FOR PRESENTERS:
Key points to raise:
This key priority is a new recommendation and is shown in full on the slide. [new 2010] [ ]
Additional information:
The conditions and devices that may preclude an exercise-based rehabilitation programme include: uncontrolled ventricular response to atrial fibrillation, uncontrolled hypertension, and high-energy pacing devices set to be activated at rates likely to be achieved during exercise.
This recommendation is linked to the recommendations about lifestyle advice for patients with heart failure. These recommendations fall into the following subgroups:
Smoking [ ]
Alcohol [ , ]
Sexual activity [ ]
Vaccination [ , ]
Air travel [ ]
Driving regulations [ ]
For more information about these recommendations see the NICE guideline and page 9 of the quick reference guide

15. Monitoring
All patients with chronic heart failure require monitoring. This monitoring should include:
a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status
a review of medication, including need for changes and possible side effects
serum urea, electrolytes, creatinine and eGFR
When a patient is admitted to hospital because of heart failure, seek advice on their management plan from a specialist in heart failure
NOTES FOR PRESENTERS:
Key points to raise:
The first of these two key priority recommendations has been amended since the 2003 guideline [2003, amended 2010] [ ]. The second is a new recommendation [new 2010] [ ].
Both recommendations are given in full on the slide.
Additional information:
There are other recommendations about monitoring which are divided into the following areas:
Clinical review
More detailed monitoring will be required if the patient has significant comorbidity or if their condition has deteriorated since the previous review. [2003] [ ]
The frequency of monitoring should depend on the clinical status and stability of the patient. The monitoring interval should be short (days to 2 weeks) if the clinical condition or medication has changed, but is required at least 6-monthly for stable patients with proven heart failure. [2003]
[ ]
Patients who wish to be involved in monitoring of their condition should be provided with sufficient education and support from their healthcare professional to do this, with clear guidelines as to what to do in the event of deterioration. [2003] [ ].
Serum digoxin
Recommendations about the monitoring of serum digoxin ( and ) can be found on page 10 of the quick reference guide
Serum natriuretic peptides
Consider specialist monitoring of serum natriuretic peptides in some patients (for example, those in whom uptitration is problematic or those who have been admitted to hospital). [new 2010]
[ ]
Please note: Recommendation states that monitoring should include serum urea, electrolytes, creatinine and eGFR. This is a minimum. Patients with comorbidities or co-prescribed medications will require further monitoring. Monitoring serum potassium is particularly important if a patient is taking digoxin or an aldosterone antagonist.

16. Discharge planning
Patients with heart failure should generally be discharged from hospital only when their clinical condition is stable and the management plan is optimised. Timing of discharge should take into account patient and carer wishes, and the level of care and support that can be provided in the community.
NOTES FOR PRESENTERS:
Key points to raise:
This key priority recommendation is the same as in the 2003 guideline [2003] [ ] and is shown in full on the slide.
Additional information:
Recommendations to cover the following subcategories within discharge planning:
Multidisciplinary team approach to heart failure management
Non-NHS agencies
Communication
Prognosis
Support groups
Anxiety and depression
End of life
All these recommendations are the same as in the 2003 guideline. Their inclusion in this guideline reflects their continued importance.

17. Serum natriuretic peptides
High levels – BNP  400 pg/ml (116 pmol/litre) or NTproBNP 2000 pg/ml (236 pmol/litre)
Raised levels – BNP 100–400 pg/ml (29–116 pmol/litre) or NTproBNP 400–2000 pg/ml (47–236 pmol/litre)
Normal levels – BNP  100 pg/ml (29 pmol/litre) or NTproBNP  400 pg/ml (47 pmol/litre)
Additional information about body of evidence reviewed:
Heart failure is a complex syndrome associated with either impaired left ventricular contraction and a reduced left ventricular ejection fraction (LVSD), or with preserved left ventricular contraction and ejection fraction (HFPEF).
The management varies according to whether the ejection fraction is reduced or preserved.
Imaging with echocardiography and evidence of left ventricular stretch (raised serum natriuretic peptides) are used to make the diagnosis and differentiate between the two types.
The likelihood of heart failure is significantly increased in the presence of previous myocardial infarction.
The outcome of heart failure is at its worst in the early stages of the presentation, hence the need for earlier diagnosis so that treatment can be offered.
The likelihood of hospitalisation and mortality are highest in the first 6 weeks after presentation, hence the time-frame.

18. 1 For more information on drug treatment see appendix D of the NICE guideline and ‘Chronic kidney disease’ (NICE clinical guideline 73).
2 Consider an ICD in line with ‘Implantable cardiovascular defibrillators for arrhythmias’ (NICE technology appraisal guidance 95).
3 NYHA class III–IV.
4 Not all ARBs are licensed for use in heart failure in combination with ACE inhibitors.
5 NYHA class II–III.
6 This does not include mixed race. For more information see the full guideline at
7 Consider CRT in line with ‘Cardiac resynchronisation therapy for the treatment of heart failure’ (NICE technology appraisal guidance 120).
Additional information
There is evidence of improved outcome for patients with heart failure due to left ventricular systolic dysfunction who are offered ACE inhibitors and beta-blockers for first-line treatment. There is also evidence that beta-blockers can be safely used by all patients.
Those who remain symptomatic despite optimal first-line treatment will have several choices of second-line treatments: aldosterone antagonists, angiotensin II receptor antagonists (ARBs) or hydralazine in combination with nitrate. This recommendation is based on evidence for better outcomes for particular second-line treatments in certain subgroups.
There was no clear evidence of benefit for drug treatment in heart failure with preserved ejection fraction (HFPEF), but advice on drug treatments for comorbid conditions is stressed.

19. Costs and savings per 100,000 population
Recommendations with significant costs
Costs
(£ per year)
Measuring BNP (or NTproBNP) and subsequent referral
42,000
Monitoring BNP (or NTproBNP) levels
3,000
Supervised cardiac rehabilitation
23,000
Estimated cost of implementation
67,000
Recommendations with significant savings
Savings
Reduced hospital admissions
86,000
Estimated saving of implementation
ADAPTING THIS SLIDE FOR LOCAL USE:
We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues.
NOTES FOR PRESENTERS:
NICE has worked closely with people within and outside the NHS to look at the major costs and savings related to implementing this guideline.
The estimated national annual changes in costs and savings arising from implementing the guideline on chronic heart failure are costs of £67,000 per year and savings of £86,000 per year.
NICE has produced a costing report that provides detailed estimates of the national costs and savings associated with implementing this guideline. NICE has also developed a costing template to calculate the local costs associated with implementing this guideline. The costs per 100,000 population are summarised in the table.

20. Discussion
How can we ensure that the appropriate patients receive transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks?
How can we ensure that we meet the requirements for BNP/NTproBNP testing?
How can we guarantee that our discharge systems facilitate discharges in accordance with the recommendations?
How can we ensure adequate monitoring to prevent readmission?
NOTES FOR PRESENTERS: These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
Additional questions:
What rehabilitation services for heart failure patients are available within our area? What can we do to either establish a rehabilitation service or ensure patients are referred to the current rehabilitation service? When discussing rehabilitation services ensure you consider the provision of exercise, psychological and emotional components to the programme.

21. Heart Improvement
Visit the NHS Improvement heart failure webpage ( for further practical support consistent with implementing the recommendations in this guideline
NOTES FOR PRESENTERS:
NHS Heart Improvement. Visit the NHS Improvement heart failure webpage ( for more information and help in implementing the recommendations in this guideline. Additionally visit the NHS improvement heart failure resource library to view resources and information relating to improvement projects in heart failure.
NHS Technology Adoption Centre
NHS Technology Adoption Centre (NTAC) expect to publish a “How to Why to” guide on Cardiac Resynchronisation Therapy (CRT) in This will provide comprehensive, relevant information for clinicians, managers, key decision makers and other stakeholders, on how to increase patients’ access to CRT services.
For more information visit:

22. Click here to go to the NHS Evidence website
Visit NHS Evidence for the best available evidence on all aspects of cardiovascular disease
Click here to go to the NHS Evidence website
NOTES FOR PRESENTERS:
If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NHS Evidence website topic page for Chronic heart failure.
For the home page go to

23. Find out more Visit www.nice.org.uk/guidance/CG108 for: the guideline
the quick reference guide
‘Understanding NICE guidance’
costing report and template
audit support
baseline assessment tool
clinical case scenarios for primary care
online educational tool
shared learning example - BNP testing
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The NICE guideline – all the recommendations.
A quick reference guide – a summary of the recommendations for healthcare professionals.
‘Understanding NICE guidance’ – information for patients and carers.
The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on or and quote reference numbers N2268 (quick reference guide) and/or N2269 (‘Understanding NICE guidance’).
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.
Audit support – for monitoring local practice.
Baseline assessment tool – the document can help you identify which areas of practice may need more support, decide on clinical audit topics and prioritise implementation activities.
Clinical case scenarios for primary care - these have been compiled to improve and assess users’ knowledge of the Chronic heart failure guideline and its application in primary care.
Online educational tool – developed in conjunction with BMJ Learning, the interactive module uses interactive case histories to improve users knowledge of the guidance. The tools are free to use and open to all. You will need to provide your address and a password to register with BMJ Learning.
Shared learning example – details the NHS Improvement project on the use of the scenarios simulation in the introduction of serum natriuretic peptide testing

24. NICE Quality Standard
Chronic heart failure
June 2011

25. Quality standards
A quality standard is a set of specific, concise statements that:
act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment and prevention
are derived from the best available evidence such as NICE guidance or other NHS evidence accredited sources
are produced collaboratively with the NHS and social care, along with their partners and service users
NOTES FOR PRESENTERS:
Key points to raise:
There are two components to a quality standard. These are qualitative statements and quantitative measures. Quality standards also include audience descriptors, definitions and data sources which support the statement measures.
Qualitative statements are descriptive statements of the key infrastructure and clinical requirements for high quality care, as well as the desirable or expected outcomes.
Commissioners will be interested in quality standards as markers of high quality care and patients and the public will see clear statements of what they can expect to receive from high quality services.

26. Chronic heart failure quality standard
Covers assessment, diagnosis and management of chronic heart failure in adults
Describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for people with chronic heart failure
Requires services commissioned from and coordinated across all relevant agencies encompassing the whole chronic heart failure care pathway
NOTES FOR PRESENTERS:
Key points to raise:
This quality standard covers assessment, diagnosis and management of chronic heart failure in adults. It is available at
This quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for people with chronic heart failure in the following ways:
Preventing people from dying prematurely.
Enhancing quality of life for people with long-term conditions.
Helping people to recover from episodes of ill health or following injury.
Ensuring that people have a positive experience of care.
Treating and caring for people in a safe environment and protecting them from avoidable harm.
The quality standard for chronic heart failure requires that services should be commissioned from and coordinated across all relevant agencies encompassing the whole chronic heart failure care pathway. An integrated approach to provision of services is fundamental to the delivery of high quality care to adults with chronic heart failure.

27. Quality statement 1
People presenting in primary care with suspected heart failure and previous myocardial infarction are referred urgently, to have specialist assessment including echocardiography within 2 weeks.
Quality measure: Proportion of people presenting in primary care with suspected heart failure and previous MI who are referred urgently, to have specialist assessment including echocardiography, with the referral indicating previous MI.
NOTES FOR PRESENTERS:
Quality statement 1: Urgent referral for people with previous myocardial infarction
Quality measure:
Structure: Evidence of local arrangements to ensure that people presenting in primary care with suspected heart failure and previous myocardial infarction (MI) are referred urgently, to have specialist assessment including echocardiography within 2 weeks.
Process: Proportion of people presenting in primary care with suspected heart failure and previous MI who are referred urgently, to have specialist assessment including echocardiography, with the referral indicating previous MI.
Numerator – the number of people in the denominator who are referred urgently, to have specialist assessment including echocardiography, with the referral indicating previous MI.
Denominator – the number of people presenting in primary care with suspected heart failure and previous MI.
Description of what the quality statement means for each audience:
Service providers ensure systems are in place to refer urgently people with suspected heart failure and previous MI, to have specialist assessment including echocardiography within 2 weeks.
Healthcare professionals ensure they refer urgently people with suspected heart failure and previous MI, to have specialist assessment including echocardiography within 2 weeks.
Commissioners ensure that services refer urgently people with suspected heart failure and previous MI, to have specialist assessment including echocardiography within 2 weeks.
People who go to their GP with symptoms of heart failure and who have had a heart attack in the past are referred urgently for assessment by a heart specialist, including an echocardiogram (a test that uses ultrasound to view the heart), within 2 weeks.

28. Quality statement 2
People presenting in primary care with suspected heart failure without previous myocardial infarction have their serum natriuretic peptides measured.
Quality measure: Proportion of people presenting in primary care with suspected heart failure without previous MI who have their serum natriuretic peptides measured before referral for specialist assessment including echocardiography.
NOTES FOR PRESENTERS:
Quality statement 2: Measuring serum natriuretic peptides
Quality measure:
Structure: Evidence of local arrangements to ensure serum natriuretic peptide measurement is available in primary care for people presenting with suspected heart failure without previous myocardial infarction (MI).
Process: Proportion of people presenting in primary care with suspected heart failure without previous MI who have their serum natriuretic peptides measured before referral for specialist assessment including echocardiography.
Numerator – the number of people in the denominator who have their serum natriuretic peptides measured before referral for specialist assessment including echocardiography.
Denominator – the number of people presenting in primary care with suspected heart failure without previous MI.
Description of what the quality statement means for each audience:
Service providers ensure systems are in place to measure serum natriuretic peptides in people presenting in primary care with suspected heart failure without previous MI before referral for specialist assessment including echocardiography.
Healthcare professionals ensure they measure serum natriuretic peptides in people presenting in primary care with suspected heart failure without previous MI before making a referral for specialist assessment including echocardiography.
Commissioners ensure serum natriuretic peptide measurement is available to primary care providers.
People who go to their GP with symptoms of heart failure but who haven’t had a heart attack in the past are offered a blood test to measure levels of substances in the blood known as serum natriuretic peptides to find out whether they should see a heart specialist.

29. Quality statement 3
People referred for specialist assessment including echocardiography, either because of suspected heart failure and previous myocardial infarction or suspected heart failure and high serum natriuretic peptide levels, are seen by a specialist and have an echocardiogram within 2 weeks of referral.
Quality measure: Proportion of people referred for specialist assessment including echocardiography, either because of suspected heart failure and previous MI or suspected heart failure and high serum natriuretic peptide levels, who are seen by a specialist and have an echocardiogram within 2 weeks of referral.
NOTES FOR PRESENTERS:
Quality statement 3: 2 week assessment and diagnosis
Quality measure:
Structure: Evidence of local arrangements to ensure that people referred for specialist assessment including echocardiography, either because of suspected heart failure and previous myocardial infarction (MI) or suspected heart failure and high serum natriuretic peptide levels, are seen by a specialist and have an echocardiogram within 2 weeks of referral.
Process: Proportion of people referred for specialist assessment including echocardiography, either because of suspected heart failure and previous MI or suspected heart failure and high serum natriuretic peptide levels, who are seen by a specialist and have an echocardiogram within 2 weeks of referral.
Numerator – the number of people in the denominator seen by a specialist and having an echocardiogram within 2 weeks of referral.
Denominator – the number of people referred for specialist assessment including echocardiography either because of suspected heart failure and previous MI or suspected heart failure and high serum natriuretic peptide levels.
Description of what the quality statement means for each audience:
Service providers ensure systems are in place for people with suspected heart failure and previous MI or suspected heart failure and high serum natriuretic peptide levels to be seen by a specialist and have an echocardiogram within 2 weeks of referral.
Healthcare professionals ensure people referred because of suspected heart failure and previous MI or suspected heart failure and high serum natriuretic peptide levels are seen and have an echocardiogram within 2 weeks of referral.
Commissioners ensure they commission services to provide specialist assessment including echocardiography within 2 weeks of referral for people with suspected heart failure and previous MI or suspected heart failure and high serum natriuretic peptide levels.
People referred urgently to a heart specialist for assessment, including an echocardiogram because of suspected heart failure, who have either had a heart attack in the past or have high levels of serum natriuretic peptides, are seen by a heart specialist and have an echocardiogram within 2 weeks of referral.

30. Quality statement 4
People referred for specialist assessment including echocardiography because of suspected heart failure and intermediate serum natriuretic peptide levels are seen by a specialist and have an echocardiogram within 6 weeks of referral.
Quality measure: Proportion of people referred for specialist assessment including echocardiography because of suspected heart failure and intermediate serum natriuretic peptide levels, who are seen by a specialist and have an echocardiogram within 6 weeks of referral
NOTES FOR PRESENTERS:
Quality statement 4: 6 week assessment and diagnosis
Quality measure:
Structure: Evidence of local arrangements to ensure that people referred for specialist assessment including echocardiography because of suspected heart failure and intermediate serum natriuretic peptide levels are seen by a specialist and have an echocardiogram within 6 weeks of referral.
Process: Proportion of people referred for specialist assessment including echocardiography because of suspected heart failure and intermediate serum natriuretic peptide levels, who are seen by a specialist and have an echocardiogram within 6 weeks of referral.
Numerator – the number of people in the denominator seen by a specialist and having an echocardiogram)within 6 weeks of referrral.
Denominator – the number of people referred for specialist assessment including echocardiography because of suspected heart failure and intermediate serum natriuretic peptide levels.
Description of what the quality statement means for each audience:
Service providers ensure systems are in place for people with suspected heart failure and intermediate serum natriuretic peptide levels to be seen by a specialist and have an echocardiogram within 6 weeks of referral.
Healthcare professionals ensure people with suspected heart failure and intermediate serum natriuretic peptide levels are seen by a specialist and have an echocardiogram within 6 weeks of referral.
Commissioners ensure they commission services to provide specialist assessment including echocardiography within 6 weeks of referral for people with suspected heart failure and intermediate serum natriuretic peptide levels.
People referred to a heart specialist for assessment, including an echocardiogram, because of suspected heart failure and raised levels of serum natriuretic peptides, are seen by a heart specialist and have an echocardiogram within 6 weeks.

31. Quality statement 5
People with chronic heart failure are offered personalised information, education, support and opportunities for discussion throughout their care to help them understand their condition and be involved in its management, if they wish.
Quality measure:
Proportion of people with chronic heart failure receiving personalised information, education, support and opportunities to discuss their care.
Evidence from experience surveys showing that people with chronic heart failure feel they have been provided with personalised information, education, support and opportunities for discussion throughout their care to help them understand their condition and be involved in its management, if they wished.
NOTES FOR PRESENTERS:
Quality statement 5: Education and self-management
Quality measure:
Structure: Evidence of local arrangements to ensure people with chronic heart failure are offered personalised information, education, support and opportunities for discussion throughout their care to help them understand their condition and be involved in its management, if they wish.
Process:
a) Proportion of people with chronic heart failure receiving personalised information, education, support and opportunities to discuss their care.
Numerator – the number of people in the denominator receiving personalised information, education, support and opportunities to discuss their care.
Denominator – the number of people with chronic heart failure.
b) Evidence from experience surveys showing that people with chronic heart failure feel they have been provided with personalised information, education, support and opportunities for discussion throughout their care to help them understand their condition and be involved in its management, if they wished.
Description of what the quality statement means for each audience:
Service providers ensure systems are in place to provide people with chronic heart failure with personalised information, education, support and opportunities for discussion throughout their care and to collect feedback from people with chronic heart failure on their experience of these systems.
Healthcare professionals ensure they offer personalised information, education, support and opportunities for discussion throughout the care of people with chronic heart failure.
Commissioners ensure they commission services that offer personalised information, education, support and opportunities for discussion throughout the care people with chronic heart failure.
People with chronic heart failure are offered personalised information, education, support and opportunities for discussion throughout their care so they can understand their condition and be involved in its management, if they wish.

32. Quality statement 6
People with chronic heart failure are cared for by a multidisciplinary heart failure team led by a specialist and consisting of professionals with appropriate competencies from primary and secondary care, and are given a single point of contact for the team.
Quality measure
Proportion of people with chronic heart failure who are cared for by a multidisciplinary heart failure team led by a specialist and consisting of professionals with the appropriate competencies from primary and secondary care.
Proportion of people with chronic heart failure given a single point of contact for the multidisciplinary heart failure team.
NOTES FOR PRESENTERS:
Quality statement 6: Multidisciplinary heart failure team
Quality measure:
Structure:
a) Evidence of a local multidisciplinary heart failure team led by a specialist and consisting of professionals with the appropriate competencies from primary and secondary care.
b) Evidence of local arrangements to ensure people with chronic heart failure are given a single point of contact for the multidisciplinary heart failure team.
Process:
a) Proportion of people with chronic heart failure who are cared for by a multidisciplinary heart failure team led by a specialist and consisting of professionals with the appropriate competencies from primary and secondary care.
Numerator – the number of people in the denominator cared for by a multidisciplinary heart failure team led by a specialist and consisting of professionals with the appropriate competencies from primary and secondary care. Denominator – the number of people with chronic heart failure.
b) Proportion of people with chronic heart failure given a single point of contact for the multidisciplinary heart failure team.
Numerator – the number of people in the denominator given a single point of contact for the multidisciplinary heart failure team. Denominator – the number of people with chronic heart failure cared for by a multidisciplinary heart failure team.
Description of what the quality statement means for each audience:
Service providers ensure the multidisciplinary heart failure team is led by a specialist and consists of professionals with appropriate competencies from primary and secondary care, and that systems are in place to provide those cared for with a single point of contact for the team.
Healthcare professionals ensure that people with chronic heart failure are cared for by a multidisciplinary heart failure team and are given a single point of contact for the team.
Commissioners ensure they commission a multidisciplinary heart failure team led by a specialist and consisting of professionals with appropriate competencies from primary and secondary care.
People with chronic heart failure are cared for by a multidisciplinary heart failure team and given a single person to contact from the team.

33. Quality statement 7
People with chronic heart failure due to left ventricular systolic dysfunction are offered angiotensin-converting enzyme inhibitors (or angiotensin II receptor antagonists licensed for heart failure if there are intolerable side effects with angiotensin-converting enzyme inhibitors) and beta-blockers licensed for heart failure, which are gradually increased up to the optimal tolerated or target dose with monitoring after each increase.
NOTES FOR PRESENTERS:
Quality statement 7: Treatment with angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists and beta-blockers
Description of what the quality statement means for each audience:
Service providers ensure systems are in place to offer ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure to people with chronic heart failure due to LVSD and ensure review after each increase in dose.
Healthcare professionals ensure they offer ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure to people with chronic heart failure due to LVSD and review after each increase in dose.
Commissioners ensure they commission services that offer ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure to people with chronic heart failure due to LVSD and review after each increase in dose.
People with chronic heart failure due to left ventricular systolic dysfunction (when the chamber that pumps blood around the body isn’t working as well as it should) are offered  drugs called ACE inhibitors and beta-blockers, and their symptoms are reviewed after each increase in dose. People who have intolerable side effects with ACE inhibitors are offered angiotensin II receptor antagonists (ARBs for short) instead of ACE inhibitors.  

34. Quality statement 7: Quality measure
Proportion of people with chronic heart failure due to LVSD who are prescribed ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors).
Proportion of people with chronic heart failure due to LVSD who are prescribed beta-blockers licensed for heart failure.
Proportion of people with chronic heart failure due to LVSD who are prescribed both ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure.
NOTES FOR PRESENTERS:
Quality statement 7 quality measure:
Structure:
a) Evidence of local arrangements to ensure that people with chronic heart failure due to left ventricular systolic dysfunction (LVSD) are offered angiotensin-converting enzyme (ACE) inhibitors (or angiotensin II receptor antagonists [ARBs] licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure.
b) Evidence of local arrangements to review people with chronic heart failure due to LVSD after each increase up to the optimal tolerated or target dose of ACE inhibitors (or ARBs) and beta-blockers.
Process:
a) Proportion of people with chronic heart failure due to LVSD who are prescribed ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors).
Numerator – the number of people in the denominator prescribed ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors).
Denominator – the number of people with chronic heart failure due to LVSD.
b) Proportion of people with chronic heart failure due to LVSD who are prescribed beta-blockers licensed for heart failure.
Numerator – the number of people in the denominator prescribed beta-blockers licensed for heart failure.
c) Proportion of people with chronic heart failure due to LVSD who are prescribed both ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure.
Numerator – the number of people in the denominator prescribed both ACE inhibitors (or ARBs licensed for heart failure if there are intolerable side effects with ACE inhibitors) and beta-blockers licensed for heart failure.

35. Quality statement 7: Quality measure continued
Proportion of people with chronic heart failure due to LVSD prescribed either ACE inhibitors or ARBs licensed for heart failure who are prescribed ACE inhibitors.
Proportion of people with chronic heart failure due to LVSD who are prescribed ACE inhibitors (or ARBs licensed for heart failure) who reach the optimal tolerated or target dose.
Proportion of people with chronic heart failure due to LVSD who are prescribed beta blockers licensed for heart failure who reach the optimal tolerated or target dose.
NOTES FOR PRESENTERS:
Quality statement 7 quality measure: (continued)
Process: (continued)
d) Proportion of people with chronic heart failure due to LVSD prescribed either ACE inhibitors or ARBs licensed for heart failure who are prescribed ACE inhibitors.
Numerator – the number of people in the denominator prescribed ACE inhibitors.
Denominator – the number of people with chronic heart failure due to LVSD prescribed ACE inhibitors or ARBs licensed for heart failure.
e) Proportion of people with chronic heart failure due to LVSD who are prescribed ACE inhibitors (or ARBs licensed for heart failure) who reach the optimal tolerated or target dose.
Numerator – the number of people in the denominator who reach the optimal tolerated or target dose of ACE inhibitor or ARB.
Denominator – the number of people with chronic heart failure due to LVSD who are prescribed ACE inhibitors or ARBs licensed for heart failure.
f) Proportion of people with chronic heart failure due to LVSD who are prescribed beta blockers licensed for heart failure who reach the optimal tolerated or target dose.
Numerator – the number of people in the denominator who reach the optimal tolerated or target dose of beta blocker.
Denominator – the number of people with chronic heart failure due to LVSD who are prescribed beta blockers licensed for heart failure.

36. Quality statement 8
People with stable chronic heart failure and no precluding condition or device are offered a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
NOTES FOR PRESENTERS:
Quality statement 8: Cardiac rehabilitation programme
Description of what the quality statement means for each audience:
Service providers ensure systems are in place for people with stable chronic heart failure and no precluding condition or device to attend a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
Healthcare professionals ensure people with stable chronic heart failure and no precluding condition are offered a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
Commissioners ensure they commission supervised group exercise-based cardiac rehabilitation programmes for people with chronic heart failure that include education and psychological support.
People with chronic heart failure are offered a supervised group exercise-based rehabilitation programme that includes information and psychological support, if it is suitable for them.

37. Quality statement 8: quality measure
Proportion of people with stable chronic heart failure and no precluding condition or device who attend a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
Proportion of people with stable chronic heart failure and no precluding condition or device who complete a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
NOTES FOR PRESENTERS:
Quality measure:
Structure: Evidence of local arrangements to ensure the availability of a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support for people with stable chronic heart failure.
Process:
a) Proportion of people with stable chronic heart failure and no precluding condition or device who attend a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
Numerator – the number of people in the denominator attending a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
Denominator – the number of people with stable chronic heart failure and no condition or device that would preclude them from exercise-based cardiac rehabilitation.
b) Proportion of people with stable chronic heart failure and no precluding condition or device who complete a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.
Numerator – the number of people in the denominator completing a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support.

38. Quality statement 9
People with stable chronic heart failure receive a clinical assessment at least every 6 months, including a review of medication and measurement of renal function.
Quality measure: Proportion of people with chronic heart failure receiving a clinical assessment in the last 6 months, including a review of medication and measurement of renal function.
NOTES FOR PRESENTERS:
Quality statement 9: Monitoring stable chronic heart failure
Quality measure:
Structure: Evidence of local arrangements to ensure people with stable chronic heart failure receive a clinical assessment at least every 6 months, including a review of medication and measurement of renal function.
Process: Proportion of people with chronic heart failure receiving a clinical assessment in the last 6 months, including a review of medication and measurement of renal function.
Numerator – the number of people in the denominator receiving a clinical assessment in the last 6 months, including a review of medication and measurement of renal function.
Denominator – the number of people with stable chronic heart failure.
Description of what the quality statement means for each audience:
Service providers ensure systems are in place for the clinical assessment of people with stable chronic heart failure at least every 6 months, including a review of medication and measurement of renal function.
Healthcare professionals ensure people with stable chronic heart failure have a clinical assessment at least every 6 months, including a review of medication and measurement of renal function.
Commissioners ensure they commission services that provide a clinical assessment for people with stable chronic heart failure at least every 6 months, including a review of medication and measurement of renal function.
People with stable chronic heart failure have a check-up at least every 6 months, including a review of their drug treatment and tests to make sure their kidneys are working properly. .

39. Quality statement 10
People admitted to hospital because of heart failure have a personalised management plan that is shared with them, their carer(s) and their GP.
NOTES FOR PRESENTERS:
Quality statement 10: Management plans for people admitted to hospital
Description of what the quality statement means for each audience:
Service providers ensure systems are in place to share personalised management plans with people admitted to hospital because of heart failure, their carer(s) and their GP.
Healthcare professionals ensure personalised management plans are shared with people admitted to hospital because of heart failure, their carer(s) and their GP.
Commissioners ensure they commission services that share personalised management plans with people admitted to hospital because of heart failure, their carer(s) and their GP.
People admitted to hospital because of heart failure, their carer(s) and their GP are provided with a copy of their personalised management plan.

40. Quality statement 10: Quality measure
Proportion of people admitted to hospital because of heart failure who have a personalised management plan when discharged.
Proportion of people admitted to hospital because of heart failure who have a personalised management plan shared with them, or their carer(s), when discharged.
Proportion of people admitted to hospital because of heart failure whose GP is given their personalised management plan when discharged.
NOTES FOR PRESENTERS:
Quality statement 10 quality measure:
Structure: Evidence of local arrangements to ensure that people admitted to hospital because of heart failure have a personalised management plan that is shared with them, their carer(s) and their GP.
Process:
a) Proportion of people admitted to hospital because of heart failure who have a personalised management plan when discharged.
Numerator – the number of people in the denominator with a personalised management plan when discharged.
Denominator – the number of people discharged after admission to hospital because of heart failure
b) Proportion of people admitted to hospital because of heart failure, or their carer(s), who have a personalised management plan shared with them when discharged.
Numerator – the number of people in the denominator, or their carer(s), who have a personalised management plan shared with them when discharged.
Denominator – the number of people discharged after admission to hospital because of heart failure.
c) Proportion of people admitted to hospital because of heart failure whose GP is given their personalised management plan when discharged.
Numerator – the number of people in the denominator whose GP is given their personalised management plan.

41. Quality statement 11
People admitted to hospital because of heart failure receive input to their management plan from a multidisciplinary heart failure team.
Quality measure
Proportion of people admitted to hospital because of heart failure whose management plan includes advice from a multidisciplinary heart failure team.
Proportion of people admitted to hospital because of heart failure seen by a specialist in heart failure.
NOTES FOR PRESENTERS:
Quality statement 11: Contribution of multidisciplinary heart failure team to management plans
Quality measure:
Structure: Evidence of local arrangements providing access to a multidisciplinary heart failure team for advice on management plans for people admitted to hospital because of heart failure.
Process:
a) Proportion of people admitted to hospital because of heart failure whose management plan includes advice from a multidisciplinary heart failure team.
Numerator – the number of people in the denominator whose management plan includes advice from a multidisciplinary heart failure team.
Denominator – the number of people admitted to hospital because of heart failure.
b) Proportion of people admitted to hospital because of heart failure seen by a specialist in heart failure.
Numerator – the number of people in the denominator seen by a specialist in heart failure.
An audit standard of less than 100% is expected for process b) to account for local service arrangements and appropriate use of resources.
Description of what the quality statement means for each audience:
Service providers ensure systems are in place for hospital staff to have access to a multidisciplinary heart failure team and a specialist in heart failure for advice on management plans for people admitted to hospital because of heart failure.
Healthcare professionals ensure they contact a multidisciplinary heart failure team for advice on management plans for people admitted to hospital because of heart failure.
Commissioners ensure they commission services that give hospital staff access to a multidisciplinary heart failure team and a specialist in heart failure for advice on management plans for people admitted to hospital because of heart failure.
People admitted to hospital because of heart failure receive input from their heart failure team into their management plan.

42. Quality statement 12
People admitted to hospital because of heart failure are discharged only when stable and receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.
Quality measure
Proportion of people admitted to hospital because of heart failure who receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.
Re-admissions for heart failure within 30 days for people with heart failure discharged from hospital.
NOTES FOR PRESENTERS:
Quality statement 12: Hospital discharge and follow-up care
Quality measure:
Structure: Evidence of local arrangements to ensure that people admitted to hospital because of heart failure are discharged only when stable and receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.
Process: Proportion of people admitted to hospital because of heart failure who receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.
Numerator – the number of people in the denominator receiving a clinical assessment by a member of the multidisciplinary heart failure team within 2 weeks of discharge.
Denominator – the number of people discharged following an admission to hospital for heart failure.
Outcome: Re-admissions for heart failure within 30 days for people with heart failure discharged from hospital.
Numerator – the number of people in the denominator re-admitted to hospital because of heart failure within 30 days.
Description of what the quality statement means for each audience:
Service providers ensure systems are in place so that people admitted to hospital for heart failure are discharged only when they are stable and that they receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.
Healthcare professionals ensure people admitted to hospital for heart failure are discharged only when stable and that they receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.
Commissioners ensure they commission services that discharge people admitted to hospital for heart failure only when they are stable and provide a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge.
People admitted to hospital for heart failure leave hospital only when their condition is stable and that they receive an assessment from a member of the multidisciplinary heart failure team within 2 weeks of leaving hospital.

43. Quality statement 13
People with moderate to severe chronic heart failure, and their carer(s), have access to a specialist in heart failure and a palliative care service.
Quality measure
a) Evidence from experience surveys that people with moderate to severe chronic heart failure, and their carer(s), felt they had access to a specialist in heart failure.
b) Evidence from experience surveys that people with moderate to severe chronic heart failure, and their carer(s), felt they had access to a palliative care service.
NOTES FOR PRESENTERS:
Quality statement 13: Specialist and palliative care for people with moderate to severe chronic heart failure
Quality measure:
Structure:
a) Evidence of local arrangements to provide people with moderate to severe chronic heart failure, and their carer(s), with access to a specialist in heart failure.
b) Evidence of local arrangements to provide people with moderate to severe chronic heart failure, and their carers(s), with access to a palliative care service.
Process:
a) Evidence from experience surveys that people with moderate to severe chronic heart failure, and their carer(s), felt they had access to a specialist in heart failure.
b) Evidence from experience surveys that people with moderate to severe chronic heart failure, and their carer(s), felt they had access to a palliative care service.
Description of what the quality statement means for each audience:
Service providers ensure systems are in place for people with moderate to severe chronic heart failure and their carer(s) to have access to a specialist in heart failure and a palliative care service.
Healthcare professionals ensure people with moderate to severe chronic heart failure and their carer(s) have access to a specialist in heart failure and a palliative care service.
Commissioners ensure they commission services providing people with moderate to severe chronic heart failure and their carer(s) with access to a specialist in heart failure and a palliative care service.
People with moderate to severe chronic heart failure and their carer(s) have access to support from a heart specialist and an end of life care (also called palliative care) service.

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NOTES FOR PRESENTERS:
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45. References
1. Petersen S, Rayner M, Wolstenholme J (2002) Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation 2. Cowie MR, Wood DA, Coats AJ et al.(1999) Incidence and aetiology of heart failure; a population-based study. European Heart Journal 20: 421–8 3. Owan TE, Hodge DO, Herges RM et al. (2006) Trends in prevalence and outcome of heart failure with preserved ejection fraction. New England Journal of Medicine 355: 251–9 4. Cowie MR, Wood DA, Coats AJ et al. (2000) Survival of patients with a new diagnosis of heart failure: a population based study. Heart 83: 505–10 5. Hobbs FD, Roalfe AK, Davis RC et al. (2007) Prognosis of all-cause heart failure and borderline left ventricular systolic dysfunction: 5 year mortality follow-up of the Echocardiographic Heart of England Screening Study (ECHOES). European Heart Journal 28: 1128–34 6. Mehta PA, Dubrey SW, McIntyre HF, Walker DM et al. (2009) Improving survival in the 6 months after diagnosis of heart failure in the past decade: population-based data from the UK. Heart 95: 1851–6 7. Stewart S, Horowitz JD (2002) Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 105: 2861–6 8. Petersen S, Rayner M, Wolstenholme J (2002) Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation
This slide is not intended for presentation. It records the references from slide 5 ‘background’