Heart Failure - Study Day 10/9/2014
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Transcript Heart Failure - Study Day 10/9/2014
Heart Failure 2014
Dr Maurice Pye
Consultant Cardiologist
York District Hospital
Heart Failure 2014
Introduction – numbers – prevalence
prognosis
NICE Guidelines – 2010 including recent
2014 guidance on complex devices
Discuss DIAGNOSIS
Go over management
Role of Secondary Care
Heart Failure: The Problem 1
Prevalence 3-20/1000 of the population
(80/1000 in 75+)
Incidence 1/1000 population per year
(10/1000 per year 85+) Median 76 years
Average GP will have 30 pts with HF and
suspect new diagnosis in 10/yr
Heart Failure: The Problem 2
5% of all hospital acute admissions (50%
readmitted within 3/12) and 2% of all hospital
bed IP days
Expected to rise 50% over next 20 years due to
aging pop
2-3 visits to the GP per year
1/3 have prolonged/severe depression
Annual mortality 30-40% in 1 st year then ~
10% yr
5yr survival in GP registries = 58% compared
to 93% for age/sex matched population
Heart Failure: Aetiology
What are the causes of heart failure ?
Heart Failure: Aetiology
Ischaemic heart disease
Hypertension (LVH risk 15x)
Cardiomyopathy: Alcohol, genetic, chemotherapy
– anthracyclines and herceptin
Valvular heart disease
Arrhythmias – tachycardiomyopathy – particularly
prolonged silent AFib
Pericardial disease – mimics --- Normal echo,
signs of right heart failure – but no intrinsic lung
disease and normal CXR
Diagnosis
How do you diagnose heart failure?
Diagnosis
Diagnosis is difficult
Symptoms, signs and investigations
Symptoms in the diagnosis of heart failure
Symptom
Dyspnoea
Orthopnoea
PND
Oedema
Sensitivity %
Specificity %
66
21
33
23
52
81
76
80
Signs in the diagnosis of heart failure
Clinical findings
Sensitivity
Specificity
Raised JVP
Crackles
Gallop
Oedema
17
29
24
20
98
77
99
80
Investigations in the diagnosis of HF: ECG
Ability of a normal ECG to exclude LV
systolic dysfunction
Sensitivity
94%
Specificity
61%
PPV
35%
NPV
98%
(However one report: 27% poor LV had N ECG)
CXR in the diagnosis of heart failure:
Cardiothoracic ratio > 50% is specific, not sensitive
Useful to exclude other causes of SOB
ECHO in the diagnosis of heart failure:
‘Best test’ for assessment LV systolic dysfunction
Of those on HF treatment only 25% have significant LV
Only 25% referred from 1o care have LV systolic dysfunction
Only 8% ? New heart failure had LV systolic dysfunction
?Diastolic dysfunction and heart failure
BNP and the diagnosis of heart failure
BNP as a screening tool for HF in 1o care
Sensitivity
Specificity
PPV
NPV
76 / 97%
84 / 87%
70 / 16%
98 / 98%
BNP /NT proBNP levels
+ with age or female
- with obesity
+ in CKD
+ in raised pulmonary artery pressure COPD, PE,
cor pulmonale
+ in AF
+ in valvular heart disease – MR , AS, MS
+ in sepsis
+ in pericardial disease
BNP in LVF some caveats
Atrial fibrillation associated with higher
BNP values so higher cut off = 200pg/ml
increased specificity from 40 to 73% with
redn in sensitivity from 95 to 85%
Adding BNP to clinical judgement in ER
increased diagnostic accuracy from 70 to
80%
BNP correctly picked up more than 90% of
patients thought to have low clinical
probability of LVF
BNP caveats
Most dyspnoeic patients with HF have
values above 400 while values below 100
have a very high negative predictive value
for HF as a cause of dyspnea
In the range between 100 and 400 plasma
BNP concentrations can have lowe
sensitivity or specificity for detecting or
excluding HF
NICE 2010 HF
Diagnosis Key Implementations 1
Refer patients with suspected heart failure and
previous myocardial infarction (MI) urgently, to
have transthoracic Doppler 2D echocardiography
and specialist assessment within 2 weeks. [new
2010]
A BNP level above 400 pg/ml (116 pmol/litre) or
an NTproBNP level above 2000 pg/ml (236
pmol/litre) urgently, to have transthoracic Doppler
2D echocardiography and specialist assessment
within 2 weeks. [new 2010]
NICE 2010 HF
Diagnosis Key Implementations 2
Refer patients with suspected heart failure
and a BNP level between 100 and
400 pg/ml (29–116 pmol/litre) or an
NTproBNP level between 400 and
2000 pg/ml (47–236 pmol/litre) to have
transthoracic Doppler 2D echocardiography
and specialist assessment within 6 weeks.
[new 2010]
NICE 2010 HF
Diagnosis Key Implementations 3
a serum BNP level less than 100 pg/ml
(29 pmol/litre) or an NTproBNP level less than
400 pg/ml (47 pmol/litre) in an untreated patient
makes a diagnosis of heart failure unlikely
the level of serum natriuretic peptide does not
differentiate between heart failure due to left
ventricular systolic dysfunction and heart failure
with preserved left ventricular ejection fraction.
[new 2010]
Caveats in role of ECHO -NICE
1.1.1.7 Perform transthoracic Doppler 2D
echocardiography to exclude important valve
disease, assess the systolic (and diastolic)
function of the (left) ventricle, and detect
intracardiac shunts. [2003]
1.1.1.8 Transthoracic Doppler 2D
echocardiography should be performed on
high-resolution equipment, by experienced
operators trained to the relevant professional
standards. Need and demand for these studies
should not compromise quality. [2003]
1.1.1.9 Ensure that those reporting
echocardiography are experienced in doing so.
[2003]
Treatment of heart failure
General measures
Drug therapy
All major trials Rx LV systolic dysfunction
General measures for heart failure
Other than drugs what do you advise/consider for
your HF patients ?
General measures for heart failure
Risk factor management
Smoking,
obesity, lipids, HT, DM,
Alcohol
Salt reduction( 3g/day) ??
Avoid
Calcium
Other
antagonists, NSAIDs, Anti-arrhythmics
Flu vacc, Pneumococcal vacc, OPD/HOME F/U
Exercise programme
Selected patients
Control AF,
anticoagulation, revascularization
Drug treatment for heart failure
Which agents prolong life?
Which agents do you use?
Drug treatment for heart failure
Diuretics
ACE inhibitors
Beta blockers
Spironolactone
Angiotensin II receptor blockers (ARBs) (sartans)
Digoxin AF +- sinus rhythm
Hydralazine and nitrates (if ACE or sartans not
tolerated)
Warfarin
NEW PARADIGM TRIAL – ACE- neprolysin-
NICE 2010 Heart Failure
Key Implementation
1.2.2.2 Offer both angiotensin-converting
enzyme (ACE) inhibitors and beta-blockers
licensed for heart failure to all patients with
heart failure due to left ventricular systolic
dysfunction. Use clinical judgement when
deciding which drug to start first. [new
2010]
ACE I/ARB: How to do it
WHO
All
patients with HF
Care: K+ > 5.5 or Cr >200 or Ur >12 or Na 130 or
SBP < 100 or > frusemide 80 mg od
WHEN
Once
HF confirmed (Ideally echo LV function)
HOW
K+ supp and NSAID and warn re hypotension
U&E’s/K+ week 1 and 4 and ? 6 monthly after
Low dosemid 1/52. Target dose 1/12
Refer if adverse effects as above
Stop
NICE 2010 ACE inhibitors
ACE inhibitors (first-line treatment)
1.2.2.5 Start ACE inhibitor therapy at a low dose
and titrate upwards at short intervals (for example,
every 2 weeks) until the optimal tolerated or target
dose is achieved. [2010]
1.2.2.6 Measure serum urea, creatinine,
electrolytes and eGFR at initiation of an ACE
inhibitor and after each dose increment[2010]
Beta-blockers: How to do it
WHO:
For
all with mild/moderate HF (NYHA II/III)
HR>60 SBP>100
Clinically stable >4/52, no AMI/UA >3/12
WHEN
Once
Euvolaemic
HOW
Bisoprolol
1.25 (1/52) 2.5(1/52)3.75(1/52)
5 (4/52) 7.5 (4/52) 10 mg
NICE guidance Beta blockers
Offer beta-blockers licensed for heart failure to all
patients with heart failure due to left ventricular
systolic dysfunction, including:
older adults and
patients with:
peripheral
vascular disease
erectile dysfunction
diabetes mellitus
interstitial pulmonary disease and
chronic obstructive pulmonary disease (COPD)
without reversibility. [new 2010]
NICE guidance Beta blockers
1.2.2.8 Introduce beta-blockers in a 'start low, go
slow' manner, and assess heart rate, blood
pressure, and clinical status after each titration.
[2010]
1.2.2.9 Switch stable patients who are already
taking a beta-blocker for a comorbidity (for
example, angina or hypertension), and who
develop heart failure due to left ventricular
systolic dysfunction, to a beta-blocker licensed for
heart failure. [new 2010]
Spironolactone: How to do it
WHO
All
patients with moderate/severe HF
Care K+ > 5.0 or Cr >221
WHEN
Once
stabilized on ACE I
HOW
Dose
25 mg/day
U&E’s/K+ week 1 and 4 and ? 3-6 monthly after
Aldosterone Antagonist NICE 2010
Aldosterone antagonists (second-line treatment)
See also recommendations 1.2.2.3 and 1.2.2.4.
1.2.2.10 In patients with heart failure due to left
ventricular systolic dysfunction who are taking
aldosterone antagonists, closely monitor
potassium and creatinine levels, and eGFR. Seek
specialist advice if the patient develops
hyperkalaemia or renal function deteriorates[22].
[new 2010]
Lives saved with Rx
TRIAL
HOPE
SOLVD-P
SOLVD-R
MERIT
CIBIS
RALES
COPERNICUS
Lives saved/1000/year
<1
7
17
38
42
52
70
Heart failure - whats on the horizon
New Ace
inhibitor Neprolysin
inhibitor PARADIGM HF study
ECS 2014
Previous Guidance TA95 2006
For Complex devices CRT or ICD
ICD if;
LVEF
<35%, NSVT on Holter AND positive V-
STIM
OR
LVEF
<30%
QRS >120ms
No worse than NYHA 3
High risk condition
Secondary prevention
Previous Guidance TA120 2007
CRT if
NYHA 3
or 4
Sinus Rhythm
Optimal medical Rx
QRS > 150ms OR 120-149ms with echo
dyssynchrony
EF <35%
More Data since 2007
ICD
DEBUT
2003
DINAMIT 2004
SCD-HeFT 2005
IRIS 2009
No benefit early post MI
Benefit in non - ischaemic cardiomyopathy
More Data
CRT
RETHINQ
2007
PROSPECT 2008
REVERSE 2008
MADIT CRT 2009
RAFT 2010
ECHO-CRT 2013
Lack of benefit (harm) in normal QRS, benefit
in NYHA 1 and 2
Echo dyssynchrony assessment unhelpful
NICE GUIDANCE 2014
ANY HEART FAILURE, LVEF ≤ 35%
QRS
duration
NYHA 1
NYHA2
NYHA3
NYHA4
<120ms
ICD IF THERE IS A HIGH RISK OF SCD
NO DEVICE
120-149ms,
no LBBB
ICD
ICD
ICD
CRT-P
120-149ms
with LBBB
ICD
CRT-D
CRT-P/D
CRT-P
≥ 150ms
CRT-D
CRT-D
CRT-P/D
CRT-P
ICD indications in 2014
Non – ischaemic cardiomyopathy
NSVT / VT STIM no longer criteria
ICD for high risk with normal QRS duration
EF < 35% (rather than 30%)
ICDs, Biventricular Pacemakers and
Combined CRT-D
Given NICE guidance and based on
contemporary evidence there are going to
be a lot more complex devices implanted
into patients with HF due to LV systolic
dysfunction
Estimates of increase of 2x more patients
receiving devices
Who is going to pay? – at present Specialist
Commissioning Group – but they are trying
to pass back to CCG
Combined Biventricular
Pacemaker and ICD device
Suspected Heart Failure-what to
do in general practice 2014
If previous MI refer urgently to cardiologist
Check BNP - If severely elevated REFER
urgently for an echocardiogram and
cardiology opinion
If moderately elevated refer for cardiology
opinion within 6 weeks
Suspected Heart Failure-what to do
in general practice 2014
Baseline investigations (FBC,U+E Cr,T4)
Start diuretics (frusemide) + non pharmacological
Rx
**Anticoagulate with warfarin if in Afib
**If echo confirms then Rx with ACE- 1st and
then a few weeks later betablockers = start low/go
slow.
**Consider spironolactone (monitoring K+ )
Heart Failure-what a cardiologist
can do?
Confirm diagnosis in borderline cases
Consider other diagnoses
Investigate underlying cause – especially if
there is any revascularisation or valve lesion
issue
Assess 24 hr heart rate in Afib
Assess for DEVICE THERAPY
NICE guidance 2010
1.5.1 Referral for more specialist advice
the initial diagnosis of heart failure – valvular
heart disease, need for revascularisation,
dysrhythmias
Consideration of Device Therapy **
The management of:
severe
heart failure (NYHA class IV)& that does not
respond to treatment
heart failure that can no longer be managed effectively
in the home setting. [new 2010]
**- Dr Pye’s addition 2014
Summary
HF is increasingly prevalent.
Diagnosis is problematic use BNP and Echo.
Strong evidence base for the treatment of HF (ACE I,
BB, SPIRO).
New Drug – ACE receptor blocker and neprolysin ARB, & Digoxin cautiously.
Increasing use of Complex Device therapy.
Need more Community heart failure nurses – just
appointed a hospital based specialist nurse in HF – to
improve discharge and reduce readmission