Diagnosis and Management of Heart Failure in Geriatric In-patients: A Clinical Quality Improvement Project

Introduction

Chronic heart failure is a leading cause of hospitalisation in individuals over 65, carrying significant morbidity and mortality, with approximately 50% of patients dying within five years of diagnosis. Despite this, only 40% of patients are under the care of cardiology, a figure projected to decline further. This audit aimed to assess adherence to European Society of Cardiology and NICE guidelines for the investigation and management of heart failure in geriatric inpatients at the Norfolk and Norwich University Hospital.

Methods

We conducted a closed-loop audit of 100 patients admitted under geriatric medicine with a primary diagnosis of heart failure—50 patients before and 50 after an educational intervention. Exclusion criteria included recurrent admissions in the same year, severe valvular disease, in-patient death, or referral to palliative care. Data were collected on: investigations, pharmacological treatment, and follow-up planning (e.g., Heart Failure Specialist Nurse [HFSN] referral). The intervention consisted of departmental teaching and a presentation of initial audit findings.

Results

Post-intervention improvements included:

• NT-proBNP testing for first presentations (from 63% to 80%)
• Echocardiography for first presentations (from 55% to 80%)
• SGLT2 inhibitor use in HFpEF patients (from 19% to 35%)
• HFSN referrals (from 45% to 60% for first presentations; 32% to 43% for decompensated heart failure)

No significant changes were observed in investigation rates for decompensated HF or in prescriptions where all four pillars of HFrEF/HFmrEF therapy were present (ACEi/ARB/ARNI, beta-blocker, MRA, SGLT2i). Scepticism from geriatricians of the safety of intentional polypharmacy in the frail older CHF cohort was noted as a barrier to meeting this standard.

Conclusion

We showed that through an educational intervention we could improve diagnostic and treatment standards of heart failure in geriatric patients. Ongoing staff education and systematic follow-up such as regular auditing may further optimise care and adherence to guideline-based therapy.

References

1) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, Volume 42, Issue 36, 21 September 2021, Pages 3599–3726, https://doi.org/10.1093/eurheartj/ehab368

2) 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, Volume 44, Issue 37, 1 October 2023, Pages 3627–3639, https://doi.org/10.1093/eurheartj/ehad195

3) Acute heart failure: diagnosis and management NICE guidelines (2021) https://www.nice.org.uk/guidance/cg187

4) Mebazaa A, Davison B, Chioncel O, Cohen-Solal A, Diaz R, Filippatos G, et al. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial. Lancet 2022;400:1938–52. https://doi.org/10.1016/S0140-6736(22)02076-1