Quality standard

Quality statement 3: Medication for chronic heart failure with reduced ejection fraction

Quality statement 3: Medication for chronic heart failure with reduced ejection fraction

Quality statement

Adults with chronic heart failure who have reduced ejection fraction receive all appropriate medication at target or optimal tolerated doses. [2011, updated 2023]

Rationale

It is important that adults with chronic heart failure who have reduced ejection fraction are given all appropriate medications at an optimal tolerated dose to best manage their condition and provide the best outcome. People taking these medicines should have them started and, where appropriate, the dose increased based on the input of a specialist and in accordance with their personal health needs, with regular checks to monitor any side effects, until the target or optimal tolerated doses are reached.

For quality improvement and any associated measurement work, the quality standards advisory committee (QSAC) prioritised a range of medication that NICE has evaluated for adults with chronic heart failure who have reduced ejection fraction:

  • angiotensin-converting enzyme (ACE) inhibitors, or angiotensin 2 receptor blockers (ARBs) if treatment with an ACE is not tolerated

  • beta-blockers

  • mineralocorticoid receptor antagonists (MRAs)

  • sodium-glucose co‑transporter 2 inhibitors (SGLT2i)

  • angiotensin receptor neprilysin inhibitors (ARNIs).

Measuring the uptake of prioritised medication

Users are encouraged to measure uptake of the medication prioritised by the QSAC in line with the drug's current marketing authorisation or any recommendations from NICE guidelines or NICE technology appraisal guidance.

Data on general practice prescribing of ACE inhibitors or ARBs, and beta-blockers, is available from the NHS Quality and Outcomes Framework (QOF; see QOF indicators HF003 and HF006). Data on prescribing of ACE inhibitors or ARBs, beta-blockers and MRAs on discharge from hospital is available from the National Heart Failure Audit.

The uptake of MRAs in general practice prescribing and of SGLT2i and ARNIs for people with chronic heart failure with reduced ejection fraction will need to be undertaken at a local level using any data available. This could include electronic medical records.

Outcome

a) Hospital admissions due to heart failure.

Data source: The National Heart Failure Audit contains data on hospital admission rates for heart failure.

b) Mortality due to heart failure with reduced ejection fraction.

Data source: No routinely collected national data for this measure has been identified. The National Heart Failure Audit contains mortality data for people 1 year after discharge who were admitted with heart failure and who receive disease-modifying drugs.

What the quality statement means for different audiences

Service providers (GP practices, hospitals and community providers) ensure that adults with chronic heart failure who have reduced ejection fraction are prescribed appropriate medications in line with their marketing authorisation and relevant NICE guidance (including clinical guidelines and technology appraisal guidance). These medications include ACE inhibitors, ARBs, beta-blockers, MRAs, SGLT2i and ARNIs.

They ensure that the medication is started and increased (when applicable) based on the input of a specialist and in accordance with individual health needs. They also make sure that there is monitoring for side effects after each increase in dose.

Healthcare professionals (such as GPs, specialists in cardiac care, heart failure specialist nurses and clinical pharmacists with an interest in heart failure) ensure that they prescribe appropriate medications in line with their marketing authorisation and relevant NICE guidance (including clinical guidelines and technology appraisal guidance). These medications include ACE inhibitors, ARBs, beta-blockers, MRAs, SGLT2i and ARNIs.

They ensure that the medication is started and increased (when applicable) based on the input of a specialist and in accordance with individual health needs. They also make sure that there is monitoring for side effects after each increase in dose.

Commissioners (such as integrated care systems, and NHS England) ensure that they commission services in which adults with chronic heart failure who have reduced ejection fraction are prescribed appropriate medication such as ACE inhibitors, ARBs, beta-blockers, MRAs, SGLT2i and ARNIs.

They ensure that services start medication and increase it (when applicable) based on the input of a specialist and in accordance with individual health needs. They also make sure that there is monitoring for side effects after each increase in dose.

Adults with chronic heart failure who have reduced ejection fraction (when the part of the heart that pumps blood around the body is not squeezing the blood as well as it should) are prescribed appropriate medications for heart failure and high blood pressure. (These may include ACE inhibitors, ARBs, beta-blockers, MRAs, SGLT2i and ARNIs, as well as other specialist treatments that may be right for them). The medication is started and increased (when applicable) based on input from their heart failure doctor, with check-ins for any side effects.

Definitions of terms used in this quality statement

Heart failure with reduced ejection fraction

Heart failure with an ejection fraction below 40%. [NICE's guideline on chronic heart failure in adults]

Appropriate medication

For this quality standard, the committee prioritised a range of drugs that can be used to improve the care and outcomes for people with chronic heart failure with reduced ejection fraction.

ACE inhibitors and beta-blockers are of proven benefit for people with chronic heart failure who have reduced ejection fraction, and NICE recommends them as first-line treatment.

ARBs licensed for heart failure should be considered as an alternative to an ACE inhibitor for people who have heart failure with reduced ejection fraction and intolerable side effects with ACE inhibitors.

MRAs, SGLT2i and sacubitril valsartan have also been shown to benefit people with chronic heart failure who have reduced ejection fraction. MRAs should be added to ACE inhibitors and beta-blockers if symptoms of heart failure continue, and SGLT2i may be added to optimised standard care on the advice of a heart failure specialist. Sacubitril valsartan is recommended as a treatment option for people with New York Heart Association (NYHA) class II to IV symptoms and a left ventricular ejection fraction of 35% or less who are already taking a stable dose of ACE inhibitors or ARBs.

Other specialist treatments may also be appropriate for some people and should be initiated by a heart failure specialist with access to a multidisciplinary heart failure team or after seeking specialist advice. These treatments include ivabradine, hydralazine in combination with nitrate (especially if the person is of African or Caribbean family origin and has moderate to severe heart failure with reduced ejection fraction) and digoxin. [NICE's guideline on chronic heart failure in adults, recommendations 1.4.1, 1.4.3, 1.4.7, 1.4.13, 1.4.15, 1.4.19, 1.4.22, 1.4.25 and 1.4.26, NICE's technology appraisal guidance on dapagliflozin and empagliflozin for treating chronic heart failure with reduced ejection fraction]

Equality and diversity considerations

ACE inhibitors are less effective in people of African or Caribbean family origin. Healthcare professionals should take this into account and ensure that the person receives additional treatment promptly if needed.