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Your healthcare closer to home Heart Failure Management

HeartFailure% Management - Barnet PCT Hub...Prevalence%of%HeartFailure%! Itis%es>mated%thatthe%prevalence%of%HF%is%around% 1H2%%of%the%adultpopulaon%and%this%increases%to% over%10%%in%people%aged%over%70%years

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Page 1: HeartFailure% Management - Barnet PCT Hub...Prevalence%of%HeartFailure%! Itis%es>mated%thatthe%prevalence%of%HF%is%around% 1H2%%of%the%adultpopulaon%and%this%increases%to% over%10%%in%people%aged%over%70%years

Your  healthcare  closer  to  home  

Heart  Failure  Management  

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Aims  of  this  session    � To  introduce  you  to  our  service  

� To  give  an  overview  of  heart  failure  and  specific  management  of  Heart  Failure  with  reduced  ejec>on  frac>on  (HFrEF)  

   � To  discuss  case  studies  

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What  is  Heart  Failure?    

� Heart  failure  is  a  syndrome  consis>ng  of  typical  symptoms  and  signs  (breathlessness,  fa>gue  and  oedema)  arising  as  a  result  of  cardiac  dysfunc>on.    

� Heart  failure  is  a  long-­‐term  condi>on  that  oIen  gets  worse  over  >me.  It  can’t  be  cured,  but  with  treatment  and  lifestyle  changes,  many  people  can  have  a  good  quality  of  life.  

 

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Barnet  Heart  Func>on  Improvement  Service    

�  Team   of   4   heart   failure   specialist   nurses   –   Mandy   Thornberry,   Jana  Roberts,  Carolyn  Mohamed  and  Jackie  Loughlin  

�  Clinical  lead:  Dr  Ameet  Bakhai,  Consultant  Cardiologist.      �  Pa>ents  are  seen  in  both  at  home  and  in  clinics    �  Our  role  is  to:  i.  Ensure  pa>ents  are  op>mised  on  maximum  tolerated  doses  of  medicine  

to  treat  heart  failure  with  reduced  ejec>on  frac>on,  LVEF<45%  ii.  To  manage  acute  exacerba>ons  with  aim  of  preven>ng  hospital  

admissions.  iii.  Educate  pa>ents  to  self  manage  their  condi>on  and  be  able  to  recognise  

signs  of  decompensa>on  and  know  when  to  seek  clinical  review.  iv.  Liaise   with   secondary   care   for   further   diagnos>c   tes>ng,   device  

considera>on  or  complex  management.  v.  Refer  to  appropriate  clinical  trials  (e.g.  Ironman,  Emperor  )  vi.  End  of  life  support    

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Prevalence  of  Heart  Failure    Na>onally  and  Locally    � BHF  Cardiovascular  disease  sta>s>cs  2018  state  that  around  550,00  people  in  the  UK  are  recorded  as  having  heart  failure  (HF)    

� NICE  state  that  the  true  number  (those  unrecorded/undiagnosed  HF)  is  likely  to  be  much  higher  and  es>mated  to  be  920,000  in  the  UK    

� Locally  Barnet  CCG  data  from  2017  shows  that  2,060  pa>ents  were  registered  as  ‘Diagnosed  with  LVSD  Heart  Failure’  

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Prevalence  of  Heart  Failure  �  It   is   es>mated   that   the   prevalence   of   HF   is   around  1-­‐2%   of   the   adult   popula>on   and   this   increases   to  over  10%  in  people  aged  over  70  years.    

� Males  are  affected  slightly  more  than  females.  � Data   from  the  2016-­‐17  Na>onal  Heart  Failure  Audit  highlights   that   prognosis   remains   poor;  mortality   in  pa>ents   admined   with   HF   is   9.4%   during   hospital  admission   with   a   third   of   those   discharged   dying  within  the  following  year.    

� Following  admission  to  hospital  for  HF,  survival  rates  are  similar  to  those  of  colon  cancer,  and  worse  than  those  of  breast  or  prostate  cancer.  

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What  are  the  symptoms  of  heart  failure?    

� Fluid  reten>on  –  swelling  of  the  ankles  and  or  legs  and  the  abdomen  

� Extreme  >redness  � Breathlessness  –  especially  when  lying  flat  � A  persistent  cough  � Lack  of  appe>te  � Weight  loss/gain  � High  heart  rate  

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Swelling  in  the  feet,  ankles,  legs    or  abdomen  

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Diagnos>c  Tests  � BNP  or  NT-­‐proBNP  � Echocardiogram:  LVEF  <45%  � Blood  tests:  ini>al  assessment  should  include  FBC,  U&Es,  TSH,  glucose,  fas>ng  lipid  profile  and  LFT  

� A  12-­‐lead  ECG  on  all  pa>ents  presen>ng  with  heart  failure.  

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What  are  the  causes  of    Heart  Failure?  

1.  Coronary  Heart  Disease-­‐  MI  2.  High  blood  pressure  3.  Heart  muscle  weakness  (Cardiomyopathy)  4.  Heart  rhythm  disturbance-­‐  Atrial  Fibrilla>on  5.  Heart  valve  disease,  damage  or  problems  with  the  heart  

valves  6.  Others:  thyroid  disease,  pulmonary  hypertension  (high  

pressure  in  the  lungs),  severe  anaemia,  viral  infec>on  affec>ng  the  heart  muscle,  alcohol  or  recrea>onal  drugs,  some  types  of  chemotherapy    and  congenital  heart  problems.  

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What  are  the  risk  factors  in    Heart  Failure?  

1.   Smoking-­‐  damages  the  lining  of  the  arteries  and  increases  the  risk  of  blood  clot.  

2.   High  blood  pressure-­‐  heart  muscles  thicken  over>me  to  cope  with  the  extra  workload  un>l  it  becomes  either  too  s>ff  or  too  weak.  

3.   High  cholesterol  level-­‐  high  levels  of  cholesterol  can  cause  narrowing  of  the  arteries.  

4.   Diabetes-­‐  high  levels  of  glucose  can  affect  the  walls  of  the  arteries  and  increases  fany  deposits.  

5.   Overweight    6.   Increase  alcohol  consumpNon-­‐  heavy  drinking  damages  the  heart  

muscles.  

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Managing  Heart  Failure  1.  Treat  underlying  causes  of  heart  failure.  

(abnormal  heart  rhythms,  severe  anaemia,  thyroid  problem  or  ischaemic  heart  disease)  

2.  Lifestyle  changes  3.  Medica>ons  4.  Surgery-­‐  use  of  device  (pacemaker  or  CRT),  

bypass  graI,  heart  transplant  or  valve  repair    

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Medical  Treatment  for  HFrEF  � Diure>cs  � ACE  Inhibitors  or  ARB  in  pa>ents  intolerant  of  ACE  Inhibitors    

� Evidence-­‐based  beta  blockers  �   Aldosterone  receptor  antagonist    � Entresto  –  Sacubitril/Valsartan  �  Ivabradine  � Hydralazine  -­‐  Nitrate  combina>on  � Digoxin    

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Non-­‐pharmacological  Interven>ons  � Educa>on  and  support  to  facilitate  self  care  � Symptoms  monitoring  � Manage  comorbidi>es    � Regular  physical  ac>vity      � Cardiac-­‐Pulmonary  Rehabilita>on  to  improve  func>onal  capacity,  quality  of  life  and  mortality  

� Sodium  restric>on  to  reduce  conges>ve  symptoms  

� Fluid  restric>on  in  fluid  overload  16  

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Device  based  treatment  and  surgical  interven>on  � ICD    � CRT-­‐P/  CRT-­‐D  � Surgical  interven>on  for  IHD  –  CABG,  valve  surgery  

� Heart  transplanta>on    

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Case  study  1    �  Presenta>on:  81  year  old  female  pa>ent  presen>ng  with  increasing  shortness  of  breath  

and  swollen  ankles.    �  PMx:  HTN,  Type  2  DM,  AF,  OA,  ECHO  from  2017:  LVEF  30-­‐35%,  mild  -­‐mod  MR.  �  Medica>on:  Furosemide  40  mg  od,  Bisoprolol  2.5  mg  od,  Ramipril  10  mg  od,  Merormin,  

Warfarin.    �  SH:  re>red  teacher,  lives  alone,  independent  with  ADL,  never  smoked,  rare  alcohol  

intake,  previously  able  to  walk  to  local  shops.  �  O/E:  BP  135/71,  radial  pulse  88  bpm  irregular,  SpO2  96%,  weight  80  kg  (usual  weight  76  

kg),  JVP  raised  >4  cm,  bi-­‐basal  creps,  bilateral  leg  oedema  to  mid  shin.      �  Management:  �  U&E,  FBC,  CRP,  TSH  and  NT-­‐proBNP  �  Up  >trate  Furosemide  to  fluid  offload    �  Repeat  ECHO  –  reassess  LV  func>on  +  check  on  progression  of  valvular  disease  �  24  hr  ECG,  up-­‐>trate  Bisoprolol  and/or  consider  Digoxin  to  rate  control  �  Add  Spironolactone  25mg  od  with  renal  monitoring  �  Entresto  �  Devices  considera>on  �  Emperor  study    �  Cardio-­‐pulmonary  exercise  and  Educa>onal  programme   18  

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Case  study  2  �  Presenta>on:  75  yrs  male  presen>ng  with  increased  breathlessness,  no  fluid  reten>on  �  PMH::  IHD-­‐  MI  2010,  primary  preven>on  ICD  2012,  LVEF  40%  2014,  COPD,  ex-­‐smoker,  

HTN  �   Medica>on:  Ramipril  10mg,  Bisoprolol  7.5mg  od,  Eplerenone  25mg,  Atorvasta>n  40mg  

od,  Allopurinol  100mg  od,  Sere>de  inh,  Salbutamol  inh.    �  SH:  lives  with  wife,  part-­‐>me  working  in  his  business,  no  alcohol  intake,  gave  up  smoking  

10  yrs  ago  (50  pack  Hx)  �  O/E:  BP  110/65,  HR  58  bpm  regular,  SpO2  95%,  JVP  not  raised,  weight  75  kg  (usual  

weight),  no  added  sounds  on    lung  ausculta>on,  no  leg/sacral  oedema.    �  Management:  �  Bloods  �  ECG:  TVI  anterior  leads,  QRS  156  ms  �  Repeat  ECHO  to  re-­‐assess  LV  func>on  �  To  consider  upgrade  to  CRT-­‐D  if  LVEF  <35%    �  Respiratory  opinion  �  Liaison  with  pa>ent’s  cardiologist  regarding  possible  worsening  IHD  +/-­‐  Angio      

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Summary  of  management    of  Heart  Failure  in  a  community  

1. Relieve  symptoms  and  improve  quality  of  life  

2.  Slow  disease  progression  3. Reduce  hospital  admission  4. Help  people  live  longer  

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References    � NICE:  Chronic  heart  failure  in  adults:  diagnosis  and  

management,  NG106  September  2007  �  Bri>sh  Heart  Founda>on.  Facts  and  Figures.  

hnps://www.bhs.uk/for-­‐professional/press-­‐centre/facts-­‐and-­‐figures    

� Na>onal  Cardiac  Audit  Programme  2017.  Na>onal  Heart  Failure    Audit  2016/17  Summary  Report  

hnps://www.nicor.org.uk/wp-­‐content/uploads/2018/11/Heart-­‐Failure-­‐Summary-­‐Report-­‐2016-­‐17.pdf  

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Ques>ons?    

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