Transcript A look at NICE guidance Chronic Heart Failure and Not Rocket

A look at NICE guidance
Chronic Heart Failure
and Not Rocket Science
By John Barker
NICE
• Full Guidance 157
pages
• Otherwise 44
pages
What does it cover?
What does it cover?
•
•
•
•
•
•
•
•
Diagnosing heart failure
Treating heart failure
Monitoring
Referral and approach to care
Supporting patients and carers
Anxiety and depression
End of life issues
Audit
Diagnosing heart failure
Symptoms
Symptoms
• Breathless
• Fatigue
• Fluid retention
Signs
Signs
•
•
•
•
Looks tired and pale
Dyspnoea
JVP
Peripheral fluid
retention
• CVS examination
shows what?
Tests
Tests
• 12-lead ECG
• BNP (where available)
• If one is abnormal do Echo
• Other modes if echo not very
good
Other Modes of Imaging
Other Modes of Imaging
• Transoesophageal Echo
• Radionucleotide
• Cardiac MRI
conditions NICE to exclude
conditions NICE to exclude
•
•
•
•
•
•
•
•
•
•
Obesity
Chest disease - lung, diaphragm or chest wall
Venous insufficiency
Drug-induced ankles Ca channel, NSAIDs
Hypoalbuminaemia
Intrinsic renal or hepatic disease
Pulmonary embolic disease
Depression and / or anxiety disorders
Severe anaemia or thyroid disease
Bilateral renal artery stenosis
Exclusion Tests
Exclusion Tests
•
•
•
•
•
U+E
FBC
TFT
Liver
Lipids (fast)
• Chest X-ray
• Glucose (fast)
• Urinalysis
• Peak flow or
spirometry
Echo Abnormal
Echo Abnormal
• NICE - Heart failure unlikely, but if
diagnostic doubt persists consider
diastolic dysfunction and consider
referral for specialist assessment
• Me – Probably a dodgy Echo – lots of
variation between technicians
Helpful comments on Echo
Helpful comments on Echo
• The reporting of echocardiography
should be by those experienced in
doing so
• Not any codger with dodgy equipment
just cos there is a lot of demand for
echo’s
Treating heart failure
Treating heart failure
A
B
C
D
D
D
•
•
•
•
•
•
ACE (A2RB) LV systolic dysfunction then
Beta Blocker
Ca chan (Amlodipine if Hypertension)
Diuretics (Spironolactone)
Diuretics for congestive symptoms
Dig if still symptomatic
or if has AF
Treating heart failure
• ACE Titrate Eg each 2 weeks
• Recheck Biochem each time (GPP)
• Beta Blocker start low go slow
• Spironolactone if symptoms despite the
above. Monitor U+E
Treating heart failure
Resynchronisation
• EF <35%
• Drug refractory Symptoms
• QRS >120ms
Discuss Contraception
Monitoring
Monitoring
•
•
•
•
Function
Fluid
Rhuthm
Lab
Referral and approach to
care
Referral and approach to
care
•
•
•
•
•
Not respnoding
Severe
Valve Probs
Co morbidities
Pregnant or Planning
Supporting patients and
carers
Supporting patients and
carers
• Communicate
• Share responsibility with
patient
• MDT
Anxiety and depression
Anxiety and depression
• Consider in all
• Consider effects of
drugs for depression
End of Life Issues
• Symptoms, Psycho, Social –
plan end of life
• Discuss Uncertainty and
Sudden death
• Assess needs Early
• All have access to Palliative
Care specialist
Audit