NICE, audit and heart failure care

The national heart failure audit1 in England and Wales continues to grow and provides vital data for planning heart failure services. The first formal report relates to over 6000 patients who were the first 10 patients admitted with a primary diagnosis of heart failure each month to one of 86 hospitals contributing data in 2008-09. Most had left ventricular systolic dysfunction, but an echocardiogram result was available in only 75%. In-patient mortality was 12% and in survivors, 80% were receiving an ACE inhibitor (or angiotensin receptor blocker (ARB)), 50% a β blocker and 30% an aldosterone antagonist at discharge.

The audit for 21 000 patients hospitalised with heart failure in 2009–10 is also available.2 In-hospital mortality had fallen slightly to 10.5%, but there was no dramatic change in drug prescription rates. Some subsets of patients were particularly likely to be actively treated (men aged 55–64, β blocker prescription rate >70%), and others much less likely (women aged >85, β blocker prescription rate 40%). Aldosterone antagonists were still prescribed for less than half the population.

Two striking features stand out from the data from both audits. First, prescription rates vary greatly, with age—older patients and women being less likely to be treated—and with admission ward—patients admitted to cardiology wards being much more likely to receive active treatment. Second, pharmacological treatment was better for patients admitted under cardiologists, and so was survival. Although a minority of patients admitted with heart failure are managed by cardiologists, the survival benefit persists after correction for age and sex (and other confounders).

The undertreatment of elderly patients with heart failure is a particular cause for concern at a time when patients aged >80 represent an increasing proportion of admissions for heart failure.3 Treatment of older patients is hampered by their associated comorbidities and polypharmacy …