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Patient population with heart failure due to LVSD*

*N.B. Codes required to be present from both groups to qualify a patient for inclusion

Beta-blocker prescription codes Licensed for Heart Failure (prescribed in the last 6 months)

bdf..%
bdl..%
bdm..%

But not a Beta-Blocker Unlicensed for Heart Failure (prescribed in the last 6 months)

bd...%
(Excluding bdf..% bdl..% bdm..% )

Beta-blocker contraindications: Latest - persistent

14LL. H/O: betablocker allergy
TJC6. Adverse reaction to betablockers
TJC61 Adverse reaction to acebutolol
TJC62 Adverse reaction to atenolol
TJC63 Adverse reaction to labetalol
TJC64 Adverse reaction to metoprolol
TJC65 Adverse reaction to nadolol
TJC66 Adverse reaction to oxprenolol
TJC67 Adverse reaction to sotalol
TJC68 Adverse reaction to timolol
TJC6z Adverse reaction to betablockers NOS
U60B7 [X]Beta-adrenoreceptor antagonists causing adverse effects in therapeutic use, not elsewhere classified
ZV14C [V]Personal history of betablocker allergy
U60B9 [X]Adverse reaction to bisoprolol
U60BA [X]Adverse reaction to carvedilol
U60BB [X]Adverse reaction to nebivolol
ZVu6i [X]Personal history of allergy to bisoprolol
ZVu6o [X]Personal history of allergy to carvedilol
ZVu6q [X]Personal history of allergy to nebivolol
TJC00 Adverse reaction to practolol (v26)
TJC02 Adverse reaction to propranolol (v26)

Beta-blocker contraindications: expiring (Latest Added in the last 12 months)

8I26. Beta blocker contraindicated
8I36. Beta blocker therapy refused
8I62. Beta blocker not indicated
8I73. Beta blocker not tolerated
8I2g. Bisoprolol contraindicated
8I2h. Carvedilol contraindicated
8I2i. Nebivolol contraindicated
8I6i. Bisoprolol not indicated
8I6j. Carvedilol not indicated
8I6k. Nebivolol not indicated
8I7K. Bisoprolol not tolerated
8I7L. Carvedilol not tolerated
8I7M. Nebivolol not tolerated
8IAS. Bisoprolol therapy refused
8IAT. Carvedilol therapy refused
8IAV. Nebivolol therapy refused

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Heart Failure

G58.. Heart failure
G580. Congestive heart failure
G5800 Acute congestive heart failure
G5801 Chronic congestive heart failure
G5802 Decompensated cardiac failure
G5803 Compensated cardiac failure
G5804 Congestive heart failure due to valvular disease
G581. Left ventricular failure
G5810 Acute left ventricular failure
G582. Acute heart failure
G583. Heart failure with normal ejection fraction
G584. Right ventricular failure
G58z. Heart failure NOS
G1yz1 Rheumatic left ventricular failure
662f. New York Heart Association classification - class I
662g. New York Heart Association classification - class II
662h. New York Heart Association classification - class III
662i. New York Heart Association classification - class IV
 

Codes for LVSD

585f. Echocardiogram shows left ventricular systolic dysfunction
G5yy9 Left ventricular systolic dysfunction
G5yyD Left ventricular cardiac dysfunction

Exclusion codes (Every 12 months)

9hH.. Exception reporting: heart failure quality indicators
9hH0. Excepted from heart failure quality indicators: Patient unsuitable
9hH1. Excepted from heart failure quality indicators: Informed dissent
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Ace inhibitor contraindications; persistent

14LM. H/O: angiotensin converting enzyme inhibitor allergy
U60C4 [X]Angiotensin-converting-enzyme inhibitors causing adverse effects in therapeutic use
ZV14D [V]Personal history of angiotensin-converting-enzyme inhibitor allergy
TJC77 Adverse reaction to captopril
TJC78 Adverse reaction to enalapril
TJC79 Adverse reaction to ramipril

Ace inhibitor contraindications; expiring (12 months)

8I28. Angiotensin converting enzyme inhibitors contraindicated
8I3D. Angiotensin converting enzyme inhibitor declined
8I64. Angiotensin converting enzyme inhibitor not indicated
8I74. Angiotensin converting enzyme inhibitor not tolerated

AII antagonist contraindications: persisting

14LN. H/O: angiotensin II receptor antagonist allergy
U60CB [X]Angiotensin II receptor antagonists causing adverse effects in therapeutic use
ZV14E [V]Personal history of angiotensin II receptor antagonist allergy

AII antagonist contraindications: expiring (12 months)

8I2H. Angiotensin II receptor antagonists contraindicated
8I3P. Angiotensin II receptor antagonist declined
8I6C. Angiotensin II receptor antagonist not indicated
8I75. Angiotensin II receptor antagonist not tolerated

Ace inhibitor prescription codes (prescribed in the last 6 months)

bi...%
bA…%
bk6..%

AII antagonist prescription codes (prescribed in the last 6 months)

bk3.. - bk5z.
bk7.. - bk9z.
bkB..%
bkC..%
bkD..%
bkI..%
bkH..%
bkJ..%
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Heart failure 004.1 Rationale

The evidence base for treating heart failure due to LVSD with beta-blockers6, 7 is at least as strong as the evidence base guiding the HF 3 indicator on ACE inhibitors (Level Ia), with a 34% reduction in major endpoints of beta-blockers on top of ACE inhibitors compared to placebo, and is a standard recommendation in all heart failure guidelines including NICE. The belief that beta-blockers are contra-indicated in heart failure was disproved, at least for the licensed beta-blockers, in the late 1990s and in some countries (especially Scandinavia) beta-blockers have never been contraindicated in heart failure. Furthermore, there are no data to suggest excess risk in the elderly (SENIORS with nebivolol only randomised people over 75 with significant benefits and no safety signal) and there are no contra-indication for use in people with chronic obstructive pulmonary disease COPD.

However, despite the evidence above, initiating beta-blockers in HF, or switching from one not licensed for HF, is more difficult because of the need to titrate from low doses and small increments over repeated visits. Patients also often suffer a temporary deterioration in symptoms with beta-blocker initiation which needs monitoring.

The British National Formulary (BNF) states that “the beta-blockers bisoprolol and carvedilol are of value in any grade of stable HF and LVSD; nebivolol is licensed for stable mild to moderate HF in patients aged over 70, beta-blocker treatment should be initiated at a very low dose and titrated very slowly over a period of weeks or months by those experienced in the management of HF. Symptoms may deteriorate initially, calling for adjustment of concomitant therapy

NICE clinical guideline CG108 and SIGN clinical guideline 95 recommend that beta-blockers licensed for HF are used as first-line therapy in all patients with HF due to LVSD. CG108 recommends that beta-blockers are used in patients with defined co-morbidities such as older adults and those with peripheral vascular disease (PVD), erectile dysfunction (ED), DM, interstitial pulmonary disease and COPD without reversibility. The only co-morbidities with a clear contra-indication to beta-blocker use are those with asthma and reversible airways obstruction (these groups were excluded from clinical trials).

Contractors are advised that patients already prescribed an unlicensed beta-blocker prior to diagnosis of HF due to LVSD do not have their drug therapy changed to meet the criteria of this indicator. Those patients already prescribed an unlicensed beta-blocker will be excluded.

Further information:

NICE CG108. Chronic HF: management of chronic HF in adults in primary and secondary care. 2010.
http://guidance.nice.org.uk/CG108/niceguidance/pdf/english (2010)

NICE quality standard. Chronic HF. 2011.
http://www.nice.org.uk/media/D6F/93/CHFQualityStandard.pdf
(2011)

SIGN clinical guideline 95 (2007). Management of chronic heart failure.
http://www.sign.ac.uk/guidelines/fulltext/95/index.html

Heart failure 004.2 Reporting and verification

See indicator wording for requirement criteria.

Patients already prescribed a beta-blocker unlicensed for heart failure will be excluded from this indicator.

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Prepared By Jean Keenan