Prescribing standards for heart failure with reduced ejection fraction

Heart failure is a serious disease in which the circulatory demands of the body are not sufficiently maintained by the heart. Symptoms of heart failure as a result of insufficient cardiac output include breathlessness, ankle swelling and fatigue, with associated signs of raised jugular venous pressure, peripheral oedema and pulmonary crackles. The National Institute of Clinical Excellence (NICE) guideline NG106, together with NICE Technology Appraisal 679,European Society of Cardiology (ESC) 2021 guidelines and the National Heart Failure Audit (NHFA) 2021 summary report, have provided guidance towards achieving efficacious and high quality pharmacological treatment. 

The objective of this study was to audit the management of heart failure treatment at a district general hospital based on the standards set by NG106 and the other guidelines mentioned above.

Audit standards:

  1. 100% of patients prescribed a heart failure licensed beta blocker 
  2. 100% of patients prescribed an ACEi/ARB/sacubitril valsartan
  3. 100% of patients prescribed a SGLT2i 
  4. 100% of patients prescribed MRA (eplerenone/spironolactone)
  5. 0% of patients prescribed diltiazem or verapamil
  6. 100% of patients prescribed anticoagulation if evidence of atrial fibrillation on ECG and CHA2DS2VASc (1 or above for men and 2 and above for women)
  7. 100% of patients administered intravenous iron in the last three months, if evidence of iron deficiency
  8. 100% of patients prescribed oral/intravenous loop diuretic, if evidence of fluid overload 

Data was collected retrospectively during March 2022. Management of heart failure treatment was analysed from 15 patients in accordance with the study inclusion criteria. The collection process involved in-person visits to the cardiology wards and analysing documentation from paper charts and online biochemistry results. Limitations of the study included a delay in ethics approval leading to a reduced sample population and that the true nature of the non-adherence for the standards are unknown as sufficient documentation might have provided evidence for adherence rather than non-compliance. 

Key findings

The clinical audit revealed non-adherence of standards 1, 2, 3 and 4, while standards 5, 6, 7 and 8 were met. 

  • Non-adherence for standard 1 was 7 percent 
  • Non-adherence for standard 2 was 21.4 percent
  • Non-adherence for standard 3 was 50 percent
  • Non-adherence for standard 4 was 33.3 percent.

Standards 1, 2, 3 and 4 comprised essential treatment regimens for heart failure, such as the usage of beta blockers, angiotensin converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), sacubitral valsartan, mineralocorticoid receptor antagonists (MRA) and SGLT2i agents. 

Improvements in clinical management are crucial for enhancing patient care as non-adherence to audit standards 1, 2, 3 and 4 were found to be rooted in several causes such as inadequate documentation with manual accessibility impediments, and lack of clinical leadership in prescribing education and awareness. 

Multiple improvements can be implemented to improve future audit results and overall quality of patient care. Such avenues of improvement include: 

  • implementation of a heart failure treatment chart
  • appointment of a heart failure clinical lead such as a pharmacist, nurse or doctor with expertise in this field
  • reinforcing awareness of current clinical practices in routine communication channels. 

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.


Get the latest clinical pharmacy articles direct to your inbox