The Waikato Integrated Heart Failure Service (WIHFS)

Debbie Chappell

CNS Heart Failure

Taumarunui/Te Kuiti/Otorohanga/Te Awamutu

The Waikato Integrated Heart Failure Service Team

HF CNSs:

• Julie Jay, Eileen Gibbons, Karyn Haeata,Debbie Chappell, Simona Inkrot, Catherine Callagher

Cardiologists:

• Mark Davis, Gerry Devlin, Raewyn Fisher

Sonographers

HF in Aotearoa/NZ

2 % Heart Failure prevalence in Western societies

HF Incidence is rising with an ageing population and the improved treatment and survival of heart disease

Median survival of 3.5 years after initial HF admission in NZ

One-year HF mortality rates after initial hospital admission are between 25 and 35%

Maori patients admitted with HF are significantly younger than NZ European: mean age 62 vs. 78 years

McMurray et al., 2012; Wasywich et al, 2010; Schaufelberger et al., 2004; Wall et al., 2012

Refresher A&P

Heart Failure is a clinical syndrome where the heart is unable to pump blood at a rate required by the body, patients present with some or all of the following features:

Symptoms typical of heart failure(breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling)

AND

Signs typical of heart failure(tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly)

AND

Objective evidence of structural or functional abnormality of the heart at rest(cardiomegaly, third heart sound, cardiac murmurs, abnormality on the echocardiogram, raised natriuetic peptide concentration)

Definition

Normal HF-REF HF-PEF

Some causes of heart failure

• Coronary artery disease• Hypertension• Valvular heart disease• Cardiomyopathies• Endocrine disorders-thyrotoxicosis• Genetic conditions• Congenital heart disease• Inflammatory• Chronic arrhythmias

• Also think of co morbidities – diabetes, obesity, COPD

Pathophysiology

Compensatory mechanisms of acute heart failure• Sympathetic nervous system activation • Renin-angiotensin system activation• LV remodelling

OUTCOME:• Vasoconstriction – Increased HR, SV leads to increased CO• Attempt to maintain cardiac output and vital organ perfusion –

heart, brain, kidneys

Maladaptation

• Compensatory mechanisms become “maladaptive” in chronic heart failure

OUTCOME:- Excessive vasoconstriction- Increased afterload- Excessive salt and water retention- Electrolyte abnormalities- Arrhythmias

Investigations

• Observations – TPR BP (lying/standing), weight, height BMI

• ECG – old and new changes

• Bloods – CBC, U&E, Cardiac enzymes, NT-pro BNP, LFT,

Cholesterol, TFT• CXRay – old and new

• ECHO- normal EF >55%, moderate – severe HF<40%

Treatment Options – medical vs intervention

Pharmacological

- Diuretics

-ACEi

-Beta-blockers

-Other drugs

Non pharmacological

-fluid management

-nutrition

-physical activity

-smoking

-psychosocial support

-other factors

Case studies• 75 year old female• History incr SOBOE (getting

worse)• Bilateral pitting oedema• JVP +2, chest clear

• History hypertension• Dip stick, LFT, U&E • NT pro BNP 400 pg/mL• Refer - ECHO normal LV,

elevated filling pressures, HFpEF• Treatment options

• 49 year old male• Bilateral oedema, pants tight• Appetite depressed• JVP normal, ascites, ? pulsatile

liver• Jaundiced

• Dip stick (bilirubin)• LFT - abnormal• NT pro BNP – normal• Renal – normal• Check ? Hepatitis, alcohol, blood

transfusion

Aims of treatment / nursing role

• Improve symptoms – fluid restrict, daily weigh, medication

• Improve LV function – medication, medical intervention

• Improve exercise tolerance – moving, pacing themselves

• Improve patient education & self-management – HF booklet

• Decrease hospital admissions - improve survival

• End of life care

CNS led interventions for HF patients

Decreased hospitalisation, decreased number of events, readmissions and days in hospital

Improved survival

Cost effective

Improved self-care behaviour

Stromberg et al., 2003; Phillips et al., 2005

Referral CriteriaInclusion:• Patients with possible heart failure and/or at high risk for heart failure in the community, e.g.

previous MI, family history of cardiomyopathy• Patients readmitted for heart failure within 3 months • Heart failure patients with significant co-morbidities affecting optimisation of treatment• “Shared care” for end stage/palliative care

Exclusion:• Lack of consent from patient• Acute coronary syndrome• Patients already under the care of a cardiologist, unless referred by this cardiologist

(inclusion criteria must be satisfied)

COMPONENTS OF WIHFS• Specialist clinics (CNS and cardiologists), Home visits, Telephone care

– Patient and family/whanau education: heart failure knowledge and self-care– Clinical monitoring– Titration of heart failure medications in consultation with GP and/or cardiologist

• Professional education/CME for other health professionals and community teams

Thank you

Questions?

Debbie Chappell – Taumarunui Te Kuiti/Otorohanga/Te Awamutu

0212419452

07 8785192