NPC Archive Item: More improvement needed in the drug management of heart failure

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8th February 2011

The National Heart Failure audit 2010 confirms the improvements suggested last year in the use of key treatments for heart failure, such as ACE inhibitors and beta blockers. However, more could still be done to ensure patients are provided with the full range of optimal treatments to manage their symptoms and improve their quality of life. Beta blockers, in particular, would seem underused. Mortality rates were found to be significantly better for those who had access to specialist care.

Health professionals should continue to follow the recently updated NICE guidance on the management of heart failure. ACE inhibitors and beta-blockers licensed for heart failure should be considered as first-line treatments,using clinical judgement to decide which drug to start first. Second-line options should be started only after specialist advice. This audit recommends that all secondary care service providers should streamline the heart failure care pathway to ensure all patients, regardless of admission ward, have access to the medication recommended by NICE, managed by specialist staff. For primary care providers, this highlights the importance of thorough follow-up of patients with heart failure after discharge from hospital to check that prescribing is in line with NICE guidance and, in particular, that medication doses are optimised to target, where appropriate.

What did the audit find?
The National Heart Failure audit 2010 focused on the care and treatment of all patients with an unscheduled admission to hospital with heart failure. The main purposes of these audits are to measure the quality of care and clinical outcomes, enabling comparisons between Trusts or Health Boards and bring about improvement where necessary. Below is a summary of some of the key findings from the second 12 months of the national roll out of the audit between April 2009 and March 2010.

Beta blockers:
The audit suggested that beta blockers were being underused: of 17,523 patients with recorded data on beta-blockers, 10,544 (60%) were prescribed them (see figure 1). The audit also highlighted that of 5,214 patients with a reported dose of a beta blocker, 66% received less than half the target dose. Men and patients aged under 75 years were likely to receive higher doses.

ACE inhibitors and angiotensin II receptor antagonists (A2RAs):
The audit found that of 19,240 patients, 14,421 (75%) were reported to have been prescribed these agents (see figure 1). Of 5,929 patients with a reported dose of an ACE inhibitor, 49% received less than half the target dose. Men, patients aged under 75 years and those with hypertension or diabetes were more likely to receive target doses. As with beta blockers, doses may have been titrated up at a later stage but, in clinical practice, the authors of the audit state this often does not happen unless the patient receives specialist follow-up.

Figure 1: Drug treatment on discharge from hospital

Source: National Heart Failure audit. Copyright © 2010, The NHS Information Centre.

Prognosis and palliative care:
The prognosis of heart failure remains poor, even for patients aged under 75 years, despite current therapy. There is substantial scientific evidence that more might be done. Despite the poor prognosis access to palliative care is very low. NICE highlighted the considerable unmet palliative care needs of patients with heart failure in 2003.

Mortality and specialist care:
Within the year of admission for heart failure, 32% of patients died. Mortality is significantly better for those who have access to specialist care. Mortality at one year in those followed up by cardiologists or by specialist heart failure services is only 23%.

More information on heart failure can be found on the heart failure floor of NPC

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Related PJ Online article: Heart failure patients get less than half target dose