Heart failure: the prognosis is poor

Providing services to patients with heart failure costs the NHS an estimated £625 million per year, and it is ranked in the top ten diagnoses for use of hospital beds, placing a significant demand on hospital facilities and resources through emergency admissions and re-admissions. Almost 90% of heart failure admissions are emergency admissions1 and account for 5% of all emergency medical admissions. Survival rates for heart failure are worse than some cancers, with annual mortality ranging from 10% to 50% and a high risk of sudden death. However, the number of deaths directly attributed to heart failure underestimates the actual number of deaths it contributes to, which may be in excess of 100,000 per year. This is because of guidance given on death certificates, which advises that heart failure is not a cause, but a mode of death. This often discourages doctors from recording heart failure as the underlying cause of death. Instead, other causes of death, such as coronary heart disease, are more commonly recorded. More than 80% of patients who die in the weeks, months and years after a heart attack will first develop heart failure.2 With the aim of providing national comparative data to help clinicians and managers improve the quality of service and outcomes for patients suffering from heart failure, the National Heart Failure Audit was first commissioned in 2007 by the Healthcare Quality Improvement Partnership (HQIP). In a 2005 national review of coronary heart disease services, the Healthcare Commission found that, despite making progress in implementing the National Service Framework (NSF), progress in meeting the heart failure standards had been slow.3 In response, two further pieces of work were commissioned to provide an in-depth picture of the quality of heart failure services across the country. A subsequent review of heart failure services in 20074 showed that progress had been made in the two years after the NSF review. However, there was still variation across the country in relation to the confirmation of diagnosis, access to evidence based treatment and heart failure specialist staff. This variability appeared to have an impact on patient outcomes. Data pooled for the years 2002/2003 and 2004/2005 demonstrated wide variation in the level of observed re-admission and mortality across PCTs in England, when compared with expected levels. A second piece of work5 focused on the in patient admission routes and access to diagnostics and key treatments. The results indicated that many patients admitted to hospitals in England, Wales and Northern Ireland are not managed fully in accordance with national and international evidence based guidelines. Only a minority of patients with heart failure were seen, or followed up, by a specialist service. While the majority of Trusts and Health Boards have a lead consultant for the care of patients with heart failure, only 22% of patients admitted to hospital with heart failure were referred to specialist or a general cardiologist. Managed by the NHS Information Centre for health and social care, in partnership with the British Society for Heart Failure, The 2010 audit contains findings based on the detailed analysis of over 21,000 patient records from Trusts, registered with the audit across England and Wales, between April 2009 and March 2010. This number represents around 40% of heart failure patients and is a 400% increase on the numbers surveyed in the previous audit. As of June 2010, 133 (86%) NHS Trusts were registered with the audit. For the period between April and January 2010, 84 (66%) of registered Trusts submitted more than 10 records per month on a regular basis, a significant increase in numbers.

A poor prognosis

One of the key findings from the 2010 audit is that the prognosis of heart failure remains poor, even for patients under 75 years of age, despite current therapy. There is also a large difference in mortality rates between those who receive specialist cardiology services when they are admitted to hospital and those who do not. Around 32% of heart failure patients will die within a year of their hospital admission. This figure falls to 23% for those seen by a cardiologist or those who have access to specialist heart failure services. This, says the audit, underlines the need to develop specialist in-patient services for heart failure patients.