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Directed Enhanced Service for patients with LVSD

Contents:

1. Financial Details

This agreement is for the financial year 2008/09.
Practices will be paid £35 for each patient with a current diagnosis of HF due to
LVSD who are not recorded as intolerant or having a contraindication to beta-
blockers and who are treated with a beta-blocker.

2. Service Background

Promoting health and wellbeing is an essential, core function of general practice
and is not an enhanced service function. This service specification outlines an
extended level of care to be provided within general practice settings.
Heart failure is an important cause of morbidity and mortality. Prevalence of heart
failure increases steeply with age, so that while around 1% of men and women
aged under 65 have heart failure, this increases to about 7% of those aged 75-84
years and 15% of those aged 85 and above. Based on these figures, it is
estimated that as many as 570,000 people in England are affected.
3. Service Aims

This service is designed with the aim to reduce mortality from heart failure. It is
estimated that of patients with a current diagnosis of heart failure, 50% will be
due to left ventricular systolic dysfunction (LVSD) and will benefit from the
appropriate prescribing of beta-blockers.
The beta blockers that should be prescribed for this purpose are carvedilol and
bisoprolol, in accordance with the Heart Failure Medicines Management
Guidelines that have been approved for use by thr CHD service.
4. Service Criteria

The contractor has a duty to ensure that the staff involved in the provision of this
service have the relevant knowledge, and are appropriately trained in the
management of patients with heart failure.
A pre-requisite for taking part in this DES is that the practice holds and maintains
a register of patients with heart failure (HF), which is already rewarded through
the Quality and Outcomes Framework (QOF).
This enhanced service runs in addition to the care offered as per the QoF
guidelines, and practices offering this service will be expected to be achieving
maximum QoF points in this area.

5. Audit & Monitoring

The practice must maintain and keep an accurate disease register of patients
with LVD. Where the reported prevalence is significantly below/above the
expected will be expected to verify this with the PCT, details of actual prevalence
and expected prevalence is attached.
Practices will need to demonstrate that they are reviewing those patients who
have been initiated with a beta blocker, and complete a prescribing audit at the
end of the year to demonstrate this. The audit will need to evidence that
practices have taken the following into consideration.
Table 6 Practical recommendations on the use of Beta-Blockers*

Which beta-blocker and what dose?

Only two beta-blockers are licensed for the treatment of heart failure in the UK at the time of
issue of this
guideline:
• Bisoprolol (starting dose 1.25 mg once daily; target dose 10 mg once daily)
• Carvedilol (starting dose 3.125 mg twice daily; target dose 25–50 mg twice daily)
NB Carvedilol: maximum dose 25 mg twice daily if severe heart failure. For patients with
mild to moderate heart failure
maximum dose 50 mg twice daily if weight more than 85 kg – otherwise maximum dose 25
mg twice daily.
How to use?

❑ Start with a low dose (see above).
❑ Double dose at not less than two weekly intervals.
❑ Aim for target dose (see above) or, failing that, the highest tolerated dose.
❑ Remember some beta-blocker is better than no beta-blocker.
❑ Monitor heart rate, blood pressure, clinical status (symptoms, signs, especially signs of
congestion,
body weight).
❑ Check blood electrolytes, urea and creatinine one to two weeks after initiation and one
to two weeks
after final dose titration.
❑ When to down-titrate/stop up-titration, see ‘Problem solving’, below.
Advice to patient

❑ Explain expected benefits.
❑ Emphasise that treatment given as much to prevent worsening of heart failure as to
improve symptoms,
beta-blockers also increase survival.
❑ If symptomatic improvement occurs, this may develop slowly – over three to six months
or longer.
❑ Temporary symptomatic deterioration may occur (estimated 20–30% of cases) during
initiation/
up-titration phase.
❑ Advise patient to report deterioration (see ‘Problem solving’, below) and that
deterioration (tiredness,
fatigue, breathlessness) can usually be easily managed by adjustment of other medication;
GP DES 08-09
patients
should be advised not to stop beta-blocker therapy without consulting their physician.
❑ Patients should be encouraged to weigh themselves daily (after waking, before dressing,
after voiding,
before eating) and to consult their doctor if they have persistent weight gain.
Problem solving

Worsening symptoms/signs (eg increasing dyspnoea, fatigue, oedema, weight gain)
❑ If increasing congestion double dose of diuretic and/or halve dose of beta-blocker (if
increasing diuretic
does not work).
❑ If marked fatigue (and/or bradycardia, see below) halve dose of beta-blocker (rarely
necessary).
❑ Review patient in one to two weeks; if not improved seek specialist advice.
❑ If serious deterioration halve dose of beta-blocker or stop this treatment (rarely
necessary); seek
specialist advice.
Low heart rate
❑ If < 50 beats/min and worsening symptoms – halve dose beta-blocker or, if severe
deterioration, stop
beta-blocker (rarely necessary).
❑ Consider need to continue treatment with other drugs that slow the heart (eg digoxin,
amiodarone,
diltiazem) and discontinue if possible.
❑ Arrange ECG to exclude heart block.
❑ Seek specialist advice.
Asymptomatic low blood pressure
❑ Does not usually require any change in therapy.
Symptomatic hypotension
❑ If low blood pressure causes dizziness, light-headedness or confusion, consider
discontinuing drugs
such as nitrates, calcium channel blockers and other vasodilators.
❑ If no signs/symptoms of congestion consider reducing diuretic dose.
❑ If these measures do not solve problem seek specialist advice.
Note: beta-blockers should not be stopped suddenly unless absolutely necessary (there is a
risk of a ‘rebound’ increase in
myocardial ischaemia/infarction and arrhythmias); ideally specialist advice should be sought
before treatment
discontinuation.
*Adapted from McMurray et al. Practical recommendations for the use of ACE Inhibitors,
beta-blockers and spironolactone
in heart failure: putting guidelines into practice. European Journal of Heart Failure
2001;3:495–502.

5. Signature Sheet

This document constitutes the agreement between the practice and the PCT in
regards to this directed enhanced service.
Practice Stamp


Principle Signature on behalf of the Practice:

Signature

Signature on behalf of the PCT:

PRACTICE population population Expected
Prevalence Prevalence difference

Source: http://www.barkingandhaveringlmc.org.uk/updates/documents/DES07_LVSD0809.pdf