This site is intended for health professionals only

Five ways to enhance a heart failure redesign

Map of Medicine has identified ways to design services to manage heart failure that will achieve productivity improvements while maintaining safety and quality.

1 Offer both ACE inhibitors and ß-blockers licensed for heart failure to all patients with heart failure from left ventricular systolic dysfunction as first-line treatment.1

NICE guidance on heart failure, published in 2010, recommends ACE inhibitors and ß-blockers (those licensed for use in heart failure) as first-line treatment, using clinical judgment to decide which drug to start first.1  Health economic evaluations have shown both drug classes to be consistently clinically and cost-effective in reducing all-cause mortality and hospitalisation in all groups of patients with heart failure.1,2

2 Initiate ACE inhibitor therapy with the lowest-cost generic version.3

There are generic versions available for some of the ACE inhibitors that are less costly and equally as effective as branded equivalents. The volume of prescribing of ACE inhibitors is increasing significantly. Expenditure in primary care in England on medications affecting the renin-angiotensin system currently stands at over £400m per year. Prescribing generic drugs can be very cost-effective.3

3 Consider cardiac resynchronisation therapy (CRT) with a pacing device under specialist care for eligible patients with severe chronic heart failure caused by left ventricular systolic dysfunction.4

NICE guidance published in 2007 recommends the use of a pacing device in eligible patients as it may lead to significant improvements in all-cause mortality, hospitalisation for heart failure and quality of life, compared with optimal pharmacological therapy alone.4  The pacing device is considered cost-effective at an incremental cost-effectiveness ratio (ICER) of £17,000 per quality-adjusted life year (QALY) compared with the threshold set by NICE.4

4 Consider CRT with a defibrillator device (CRT-D), under specialist care, for eligible patients with severe chronic heart failure who are at risk of sudden death.4

Compared with optimal pharmacological therapy alone, CRT-D significantly reduces the incidence of sudden cardiac death and all-cause mortality.4

Over a lifetime, CRT-D is associated with a 0.99 QALY gain – which is equivalent to 361 days of full health for a patient at risk of sudden death – at an incremental cost of £23,320. This is considered to be 30% likely to be cost-effective, at a willingness to pay £20,000 per QALY when compared with optimal pharmacological therapy alone.4 However, the cost-effectiveness of CRT-D over a lifetime would be improved in patients with heart failure who have additional risk factors for sudden cardiac death.4

5 Offer a supervised group exercise programme designed for heart failure patients.5

Exercise-based cardiac rehabilitation programmes for heart failure patients have a positive effect on outcomes such as hospitalisation, exercise tolerance, symptom severity, quality of life scores and all-cause mortality for up to five years.5 Analyses have also shown exercise-based rehabilitation programmes in heart failure patients are cost-effective as the ICER is £258 per life year gained.5,6

For further information go to


The productivity considerations presented in this document are relevant to the UK. They were identified by systematically searching for and appraising productivity evidence from multiple sources, including NICE guidance, health economic databases and Zynx Health (a sister company of Map of Medicine). A productivity message explicitly states interventions that can reduce the cost of care, while maintaining or improving patient outcomes.

Actions that are believed to lead to improved productivity, but lack unequivocal clinical or economic evidence, are not included. Some productivity considerations are informed by more recent evidence than that included in relevant national guidelines. The document has been peer reviewed by an independent group of experts.


1 National Clinical Guideline Centre. Chronic heart failure: National clinical guideline for diagnosis and management in primary and secondary care. 2010

2 Yao G et al. Long-term cost-effectiveness analysis of nebivolol compared with standard care in elderly patients with heart failure: an individual patient-based simulation model. Pharmacoeconomics. 2008; 26: 879-89.

3 NHS Institute for Innovation and Improvement. Converting the potential into reality: 10 steps a commissioner can take to realise the benefits of Better Care, Better Value indicators. 2009

4 NICE. Cardiac resynchronisation therapy for the treatment of heart failure. Technology Appraisal Guidance 120. 2007

5 Georgiou D et al. Cost-effectiveness analysis of long-term moderate exercise training in chronic heart failure. Am J Cardiol 2001;87:984-8

6 Hagberg L and Lindholm L. Cost-effectiveness of healthcare-based interventions aimed at improving physical activity. Scand J Public Health 2006;34:641-53


This document is not to be substituted for a healthcare professional's diagnosis or clinical decisions.

© 2011 Map of Medicine Ltd.