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In 2017, the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) published its official document detailing standards and core components for cardiovascular prevention and rehabilitation. Building on the success of previous editions of this document (published in 2007 and 2012), the 2017 update aims to further emphasise to commissioners, clinicians, politicians and the public, the importance of robust, quality indicators of cardiac rehabilitation (CR) service delivery. Otherwise, its overall aim remains consistent with the previous publications – to provide a precedent upon which all effective cardiovascular prevention and rehabilitation programmes (CPRPs) are based and a framework for use in assessment of variation in service delivery quality. In this 2017 edition, the previously described seven standards and core components have both been revised to six, with a greater focus on measurable clinical outcomes, audit and certification. The principles within the updated document underpin the six-stage pathway of care for CR, and reflect the extensive evidence base now available within the field. To help improve current services, close collaboration between commissioners and CR providers is advocated, with use of the CR costing tool in financial planning of programmes. The document specifies how quality assurance can be facilitated through local audit, and advocates routine upload of individual-level data to the annual British Heart Foundation (BHF) National Audit of Cardiac Rehabilitation (NACR), and application for national certification ensuring attainment of a minimum quality standard. Although developed for the UK, these standards and core components may be applicable to other countries.

ObjectiveChronic heart failure with reduced ejection fraction (HF-REF) represents a major public health issue and is associated with considerable morbidity and mortality. We evaluated the cost-effectiveness of sacubitril/valsartan (formerly LCZ696) compared with an ACE inhibitor (ACEI) (enalapril) in the treatment of HF-REF from the perspective of healthcare providers in the UK, Denmark and Colombia.MethodsA cost-utility analysis was performed based on data from a multinational, Phase III randomised controlled trial. A decision-analytic model was developed based on a series of regression models, which extrapolated health-related quality of life, hospitalisation rates and survival over a lifetime horizon. The primary outcome was the incremental cost-effectiveness ratio (ICER).ResultsIn the UK, the cost per quality-adjusted life-year (QALY) gained for sacubitril/valsartan (using cardiovascular mortality) was £17 100 (€20 400) versus enalapril. In Denmark, the ICER for sacubitril/valsartan was Kr 174 000 (€22 600). In Colombia, the ICER was COP$39.5 million (€11 200) per QALY gained. Deterministic sensitivity analysis showed that results were most sensitive to the extrapolation of mortality, duration of treatment effect and time horizon, but were robust to other structural changes, with most scenarios associated with ICERs below the willingness-to-pay threshold for all three country settings. Probabilistic sensitivity analysis suggested the probability that sacubitril/valsartan was cost-effective at conventional willingness-to-pay thresholds was 68%–94% in the UK, 84% in Denmark and 95% in Colombia.ConclusionsOur analysis suggests that, in all three countries, sacubitril/valsartan is likely to be cost-effective compared with an ACEI (the current standard of care) in patients with HF-REF.

ObjectiveTimely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care. We describe the journey of people with HF in primary care from presentation through to diagnosis and initial management.MethodsWe used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis.Results36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March 2013. For 29 113 (79.2%) patients, this was first recorded in hospital. In the 5 years prior to diagnosis, 15 057 patients (41.0%) had a primary care consultation with one of three key HF symptoms recorded, 17 724 (48.2%) attended for another reason and 3967 (10.8%) did not see their general practitioner. Only 24% of those with recorded HF symptoms followed a pathway aligned with guidelines (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral.ConclusionsPatients follow various pathways to the diagnosis of HF. However, few appear to follow a pathway supported by guidelines for investigation and referral. There are likely to be missed opportunities for earlier HF diagnosis in primary care.

Context Readmission to hospital for heart failure is common after recent discharge. Remote monitoring (RM) strategies have the potential to deliver specialised care and management and may be one way to meet the growing needs of the heart failure population. Objective To determine whether RM strategies improve outcomes for adults who have been recently discharged ( Study design Systematic review and network meta-analysis. Data sources Fourteen electronic databases (including MEDLINE, EMBASE and PsycINFO) were searched to January 2012, and supplemented by hand-searching relevant articles. Study selection All randomised-controlled trials (RCTs) or observational cohort studies with a contemporaneous control group were included. RM interventions included home telemonitoring (TM) (including implanted monitoring devices) with medical support provided during office hours or 24/7 and structured telephone support (STS) programmes delivered via human-to-human contact (HH) or human-to-machine interface (HM). Data Extraction Data were extracted and validity was assessed independently by two reviewers. Results Twenty-one RCTs that enrolled 6317 patients were identified (11 studies evaluated STS (10 of which were HH, while 1 was HM), 9 studies assessed TM, and 1 study assessed both STS and TM). No trial of implanted monitoring devices met the inclusion criteria. Compared with usual care, although not reaching statitistical significance, RM trended to reduce all-cause mortality for STS HH (HR: 0.77, 95% credible interval (CrI): 0.55, 1.08), TM during office hours (HR: 0.76, 95% CrI: 0.49, 1.18) and TM24/7 (HR: 0.49, 95% CrI: 0.20, 1.18). Exclusion of one trial that provided better-than-usual support to the control group rendered each of the above comparisons statistically significant. No beneficial effect on mortality was observed with STS HM. Reductions were also observed in all-cause hospitalisations for TM interventions but not for STS interventions. Care packages generally improved health-related quality-of-life and were acceptable to patients. Conclusions STS HH and TM with medical support provided during office hours showed beneficial trends, particularly in reducing all-cause mortality for recently discharged patients with heart failure. Where ‘usual’ care is less good, the impact of RM is likely to be greater.

Background Diagnosing early stages of heart failure with mild symptoms is difficult. B-type natriuretic peptide (BNP) has promising biochemical test characteristics, but its diagnostic yield on top of readily available diagnostic knowledge has not been sufficiently quantified in early stages of heart failure. Objectives To quantify the added diagnostic value of BNP for the diagnosis of heart failure in a population relevant to GPs and validate the findings in an independent primary care patient population. Design Individual patient data meta-analysis followed by external validation. The additional diagnostic yield of BNP above standard clinical information was compared with ECG and chest x-ray results. Patients and methods Derivation was performed on two existing datasets from Hillingdon (n=127) and Rotterdam (n=149) while the UK Natriuretic Peptide Study (n=306) served as validation dataset. Included were patients with suspected heart failure referred to a rapid-access diagnostic outpatient clinic. Case definition was according to the ESC guideline. Logistic regression was used to assess discrimination (with the c-statistic) and calibration. Results Of the 276 patients in the derivation set, 30.8% had heart failure. The clinical model (encompassing age, gender, known coronary artery disease, diabetes, orthopnoea, elevated jugular venous pressure, crackles, pitting oedema and S3 gallop) had a c-statistic of 0.79. Adding, respectively, chest x-ray results, ECG results or BNP to the clinical model increased the c-statistic to 0.84, 0.85 and 0.92. Neither ECG nor chest x-ray added significantly to the ‘clinical plus BNP’ model. All models had adequate calibration. The ‘clinical plus BNP’ diagnostic model performed well in an independent cohort with comparable inclusion criteria (c-statistic=0.91 and adequate calibration). Using separate cut-off values for ‘ruling in’ (typically implying referral for echocardiography) and for ‘ruling out’ heart failure—creating a grey zone—resulted in insufficient proportions of patients with a correct diagnosis. Conclusion BNP has considerable diagnostic value in addition to signs and symptoms in patients suspected of heart failure in primary care. However, using BNP alone with the currently recommended cut-off levels is not sufficient to make a reliable diagnosis of heart failure.

Heart failure is a syndrome resulting from a structural or functional cardiac disorder. For a diagnosis of heart failure to be made, there should be symptoms or signs, such as breathlessness, effort intolerance or fluid retention, together with objective evidence of cardiac dysfunction. Heart failure is an increasingly important chronic disease syndrome, associated with poor prognosis, poor quality of life for patients, and high healthcare costs.1 w1 In the general population, where all grades of heart failure are represented, 5 year mortality is around 42%2; however, where the diagnosis is established during a hospital admission, 5 year mortality is between 50–75%,3 w2 although the prognosis has improved in the past 10 years. Studies including objective assessment of left ventricular (LV) function, usually echocardiography, indicate a prevalence of left ventricular systolic dysfunction (LVSD) of 2.9% in patients under 754 and up to 7.5% in 75–84 year olds.w3 In the largest recent prospective evaluation of heart failure in the community, definite heart failure was found in 2.3% (95% confidence interval (CI) 1.9% to 2.8%) of the population, with left ventricular ejection fraction (LVEF)

Background Relatively little is known about the prevalence of comorbidities, patterns of health care utilisation and primary care recording of clinical indicators in patients with congenital heart disease. Methods We conducted a population-based case control study using data from general practices across the UK contributing data to the QRESEARCH primary care database. The subjects were 9952 cases of congenital heart disease and 29837 matched controls. Outcome measures were: Prevalence (%) of selected comorbidities; adjusted odds ratios (OR) for risk of comorbidities, health care utilisation and clinical indicator recording. Results The overall crude prevalence of congenital heart disease was 3.05 per 1000 patients (95% CI 2.90 to 3.11). Prevalence of key comorbidities in congenital heart disease patients ranged from 2.4% (95% CI 2.1 to 2.7) for epilepsy to 9.3% (95% CI 8.8 to 9.9) for hypertension. After adjusting for smoking and deprivation, cases were significantly more likely than controls to have each of the cardiovascular comorbidities e.g. adjusted odds ratio for atrial fibrillation 7.6 (6.1 to 9.3), and also had an increased risk of diabetes, epilepsy and renal disease. Patients with congenital heart disease were heavier users of primary care than controls. congenital heart disease patients were also more likely than controls to have lifestyle and risk factor measurements recorded in primary care e.g. adjusted odds ratio for BMI recording in cases versus controls 1.23 (95% CI 1.16 to 1.31), although overall levels of recording were low. Conclusions There is a significant burden of comorbidity associated with congenital heart disease, and levels of primary care utilisation and referral to secondary care are high in this patient population. The predicted future expansion in the numbers of adults with congenital heart disease owing to improvements in survival will have implications for primary and secondary care, and not just tertiary centres offering specialist care.

Objective To ascertain time trends in rates of hospital admission, operations, in- hospital case fatality and general mortality for congenital heart disease (CHD) in England and Wales. Design Retrospective analysis of Hospital Episodes Statistics for England (April 1995-March 2004) and mortality statistics for England and Wales (1994-2003). Population All NHS patients admitted with a primary diagnosis of CHD to hospitals in England, and all deaths in England and Wales with an underlying cause of CHD. Main outcome measures Age standardised hospital admission rates, case fatality rates and death rates from congenital heart disease. Results Between 1995/96 and 2003/04 the age standardised hospital admission rate for CHD increased from 30.7 per 100,000 (95% CI 29.9-31.4) to 35.5 per 100,000 (95% CI 34.7-36.4) in males and from 28.2 per 100,000 (95% CI 27.4-28.9) to 32.8 per 100,000 (95% CI 32.0-33.6) in females. Between 1997/98 and 2003/04 in-hospital case fatality rates fell from 2.10% (95% CI 1.97-2.22) to 0.83% (95% CI 0.74-0.92). Population mortality fell steadily over the decade 1994 to 2003 in men and women, with the largest proportionate decrease in the 1-4 year age group. Conclusion Admission rates for CHD have increased over the past decade, particularly amongst patients in older age groups. There has also been a significant decrease in both in-hospital case fatality rates and in general population mortality rates. These trends are consistent with improvements in the quality of care for these patients, improvements in survival and the predicted expansion in the number of adults living with CHD.

Randomised clinical trials of drug treatment for chronic heart failure are the basis of many physicians’ beliefs about heart failure. Due to the selection bias of such studies—which preferentially recruit relatively young white men with coronary artery disease—relatively little attention has focused on gender differences in heart failure. This article provides an overview of such gender differences, based on population-based studies in North America and Europe. It is difficult to make comparisons between prevalence studies (and across time) due to differences in the case definitions employed.1 There is no “gold standard” for heart failure, and most recent studies rely heavily on echocardiography to demonstrate underlying cardiac abnormalities in patients with symptoms that might be caused by heart failure. Most studies rely on administering questionnaires regarding symptoms, a few collect information on clinical signs, and very few combine robust clinical assessment with echocardiographic data. The prevalence of left ventricular systolic dysfunction is relatively straightforward, if time consuming, to establish within a population; however, this is not synonymous with heart failure. The Framingham heart study, a large cohort study from Massachusetts in the United States, reported an estimated prevalence of heart failure of 0.8% in both genders within the age group of 50–59 years. The prevalence increases notably with advancing age, rising to 6.6% and 7.9% in men and women, respectively, aged 80–89 years.2 The US National Health And Nutrition Examination Survey (NHANES) study reported an overall prevalence of approximately 2% in both men and women aged 25–74 years, based on a clinical score system derived from the Framingham heart study.3 European data suggest a similar prevalence of heart failure of between 1–2%.4,5 In the UK, there have been two major population based echocardiographic studies of heart failure prevalence. The 1992 MONICA (monitoring trends and determinants in …