Chronic heart failure in adults

  • Quality standard
  • QS9
  • Published: 
  • Last updated: 
Download (PDF)

Quality statement 3: Medication for newly diagnosed and pre-existing chronic heart failure with reduced ejection fraction

Quality statement

Adults with newly diagnosed and pre-existing chronic heart failure with reduced ejection fraction receive all appropriate medication at optimal tolerated doses. [2011, updated 2025]

Rationale

It is important that all adults with chronic heart failure with reduced ejection fraction are given all appropriate medications at an optimal tolerated dose to best manage their condition and provide the best outcome.

Adults with chronic heart failure with reduced ejection fraction should be offered the following treatment combination to reduce the likelihood of related hospitalisation and mortality:

  • angiotensin-converting enzyme (ACE) inhibitor

    • or an angiotensin receptor-neprilysin inhibitor (ARNI)

    • or an angiotensin II receptor blocker (ARB)

  • beta-blocker

  • mineralocorticoid receptor antagonist (MRA)

  • sodium-glucose cotransporter-2 (SGLT2) inhibitor.

People's medical history, findings from their clinical assessment, their frailty status, prognosis and preferences should be used when making decisions about these medicines. They should have regular checks to monitor any side effects, until optimal tolerated doses are reached.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Process

a) Proportion of adults with chronic heart failure with reduced ejection fraction that are prescribed an ACE inhibitor, or ARNI or ARB.

Numerator – the number in the denominator that are prescribed an ACE inhibitor, or ARNI or ARB.

Denominator – the number of adults with chronic heart failure with reduced ejection fraction.

Data source: Data on general practice prescribing of ACE inhibitors or ARBs is available from the NHS Quality and Outcomes Framework (QOF; see QOF indicator HF003). Data on prescribing of ACE inhibitors (or ARBs or ARNIs) on discharge from hospital is available from the National Heart Failure Audit.

b) Proportion of adults with chronic heart failure with reduced ejection fraction that are prescribed a beta-blocker.

Numerator – the number in the denominator that are prescribed a beta-blocker.

Denominator – the number of adults with chronic heart failure with reduced ejection fraction.

Data source: Data on general practice prescribing of beta-blockers, is available from the NHS Quality and Outcomes Framework (QOF; see QOF indicator HF006). Data on prescribing of beta-blockers on discharge from hospital is available from the National Heart Failure Audit.

c) Proportion of adults with chronic heart failure with reduced ejection fraction that are prescribed an MRA.

Numerator – the number in the denominator that are prescribed an MRA.

Denominator – the number of adults with chronic heart failure with reduced ejection fraction.

Data source: Data on prescribing of MRAs on discharge from hospital is available from the National Heart Failure Audit.

d) Proportion of adults with chronic heart failure with reduced ejection fraction that are prescribed an SGLT2 inhibitor.

Numerator – the number in the denominator that are prescribed an SGLT2 inhibitor.

Denominator – the number of adults with chronic heart failure with reduced ejection fraction.

Data source: Data on prescribing of SGLT2 inhibitors on discharge from hospital is available from the National Heart Failure Audit.

e) Proportion of adults with chronic heart failure with reduced ejection fraction that are prescribed an ACE inhibitor, beta-blocker, MRA and SGLT2 inhibitor.

Numerator – the number in the denominator that are prescribed an ACE inhibitor, beta-blocker, MRA and SGLT2 inhibitor.

Denominator – the number of adults with chronic heart failure with reduced ejection fraction.

Data source: No routinely collected national data on general practice prescribing is available for all medicines in this treatment combination, but may be collected locally by healthcare professionals and provider organisations, for example from patient records. Data on prescribing of ACE inhibitors (or ARNIs or ARBs, beta-blockers, MRAs and SGLT2 inhibitors) on discharge from hospital is available from the National Heart Failure Audit.

The uptake of MRAs, SGLT2 inhibitors and ARNIs in general practice prescribing 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.

What the quality statement means for different audiences

Service providers (GP practices, hospitals and community providers) ensure that adults with chronic heart failure with reduced ejection fraction are prescribed a combination of treatments in line with the latest NICE guidance.

Healthcare professionals (such as GPs, specialists in cardiac care, heart failure specialist nurses and clinical pharmacists) ensure that they prescribe appropriate medications in line with their marketing authorisation and relevant NICE guidance (including clinical guidelines and technology appraisal guidance).

They ensure that the medication is started and increased (when applicable) in accordance with individual health needs and, if the medication requires it, based on the advice of a heart failure specialist. They also make sure that there is monitoring for side effects and symptoms of heart failure 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 with reduced ejection fraction are prescribed appropriate medication.

Adults with chronic heart failure with 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. The medication is started and increased (when applicable) with check-ins for any changes in symptoms, side effects and, depending on the medication, based on input from their heart failure doctor.

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

ACE inhibitors, beta-blockers, MRAs and SGLT2 inhibitors are of proven benefit for people with chronic heart failure with reduced ejection fraction, and NICE recommends them as first-line treatment.

ARNIs licensed for heart failure should be considered as an alternative to an ACE inhibitor for people on the maximum tolerated dose of each of ACE inhibitors, beta-blockers, MRAs and SGLT2 inhibitors who continue to have symptoms of heart failure, and for people with chronic heart failure with reduced ejection fraction who have symptoms of intolerance to ACE inhibitors (other than angioedema). Primary care prescribers should consider seeking advice from a heart failure specialist before starting someone on a angiotensin receptor-neprilysin inhibitor (ARNI).

ARBs licensed for heart failure should be considered for people with angioedema after taking an ACE inhibitor, and should be considered for people who have symptoms of intolerance of ACE inhibitors and ARNIs.

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.

People's medical history, findings from their clinical assessment, their frailty status, prognosis and preferences should be used when deciding:

  • which specific medicines and medicine combinations to use

  • the order and timing for introducing each medicine

  • the initial dose of each medicine and any subsequent dose increments

  • when and how to optimise the dose of each medicine.

[NICE's guideline on chronic heart failure in adults, recommendations 1.4.1 to 1.4.4, 1.4.8 to 1.4.12, 1.7.1 and 1.7.2 and NICE's technology appraisal guidance on ivabradine, sacubitril valsartan, 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.