Transcript Heart Failure

Heart Failure
Dr. Ali
Gpst3
Brownhill Surgery
Outline
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Risk factors
Symptoms
Signs
Investigations
Differential Diagnosis
Referral
Treatment
Risk Factors
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Smoking
DM
Obesity
Alcohol
High total chol:HDL ratio
LVH on echo
Congenital heart defects
Valvular disorders in elderly
Viral myocarditis
Family history
Drug related
Symptoms
• LVF
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SOB, Orthopnoea, PND
Decreased exercise tolerance
Lethargy
Nocturnal cough
Wheeze
• RVF
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Swelling of ankles
Abdominal discomfort due to liver distension
Nausea and Anorexia
Fatigue and Wasting
Increased weight
NYHA
Class
Patient Symptoms
Class I (Mild)
No limitation of physical activity. Ordinary physical
activity does not cause undue fatigue, palpitation, or
dyspnoea (shortness of breath).
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest,
but ordinary physical activity results in fatigue,
palpitation, or dyspnoea.
Class III
(Moderate)
Marked limitation of physical activity. Comfortable at
rest, but less than ordinary activity causes fatigue,
palpitation, or dyspnoea.
Class IV
(Severe)
Unable to carry out any physical activity without
discomfort. Symptoms of cardiac insufficiency at rest. If
any physical activity is undertaken, discomfort is
increased.
Signs
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Laterally displaced apex beat
Raised jugular venous pressure
Enlarged liver
Third or fourth heart sound (gallop rhythm)
Tachycardia
Lung crackles (persisting after coughing)
Dependent oedema (legs, sacrum)
Investigations
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12 lead ECG
Natriuretic peptides
CXR
FBC, TFT, E&E, creatinine, eGFR, LFTs, glucose and lipids
Urinalysis, peak flow, spirometry
Echo
Natriuretic Peptides
• Measurement of natriuretic peptide levels helps to determine:
• The likelihood of the presence of heart failure.
• The need for referral for specialist assessment and confirmation
of the diagnosis by echocardiography.
• The urgency of the referral.
Natriuretic Peptides
• Two types of natriuretic peptide can be measured: B-type
natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) (Local Lab uses NT-pro-BNP).
• NT-proBNP is the inactive prohormone of BNP and is secreted
from the ventricles in response to volume expansion and
pressure overload (as occurs in heart failure).
• BNP increases renal excretion of sodium (natriuresis) and
water (diuresis) and relaxes vascular smooth muscle, which
leads to vasodilation.
Natriuretic Peptides
• Increased levels of BNP or NT-proBNP are present in:
• left ventricular hypertrophy, myocardial ischaemia, atrial
fibrillation, pulmonary hypertension, hypoxia, pulmonary
embolism, right ventricular strain, chronic obstructive
pulmonary disease, liver failure, sepsis, diabetes, and renal
impairment, in people older than 70 years of age and in
women.
• Levels are lower in people who are obese or are taking drug
treatments, such as aldosterone antagonists, angiotensinconverting enzyme inhibitors, angiotensin-II receptor
antagonists, beta-blockers, and diuretics.
Referral
• Refer urgently (within 2 weeks) for specialist assessment and
echocardiography:
• People who have had a previous myocardial infarction (MI).
• People without a history of MI who have high levels of natriuretic
peptide — N-terminal pro-B-type natriuretic peptide (NT-proBNP)
level above 2000 pg/mL (236 pmol/L).
• People with severe symptoms (if admission is not indicated).
• Women who are pregnant.
Referral
• Refer within 6 weeks:
• People without a history of MI who have a NT-proBNP level
between 400–2000 pg/mL (47–236 pmol/L).
• If natriuretic peptide levels are normal (NT-proBNP less than
400 pg/mL [47 pmol/L]), a diagnosis of heart failure is unlikely.
However, referral may still be needed if:
• Clinical suspicion of heart failure persists and the person is obese
or taking drugs which lower natriuretic peptide levels (diuretics,
angiotensin-converting enzyme inhibitors, angiotensin-II receptor
antagonists, beta-blockers, or aldosterone antagonists).
• Another condition is suspected, which requires referral to a
specialist.
Differential dx
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Obesity
Respiratory disease
Venous insufficiency in legs
Drug induced (CCB,NSAIDs)
Hypoalbuminaemia
Anxiety
Anaemia
Thyroid disease
Management
Non-drug Mx:
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1. Educate
2. Discuss ways to make life easier
3. Diet
4. Lifestyle measures
5. Restrict fluid intake
6. Vaccination
7. Asses for depression
Management
While patient is awaiting referral:Drug MX:
Improve Survival
• 1. ACE-I /ARB
• 2. beta blockers.
How should I manage the person while they are
waiting to see a specialist?
• If possible, stop any drugs that may affect the person's heart
failure, such as nonsteroidal anti-inflammatory drugs
(including those bought over the counter) or calcium-channel
blockers.
• If symptoms are sufficiently severe to warrant treatment (but
not admission), start a loop diuretic:
• Furosemide 20 mg/day to 40 mg/day.
• Bumetanide 0.5 mg/day to 1.0 mg/day.
• Torasemide 5 mg/day to 10 mg/day.
• Seek specialist advise for pregnant women before initiating
any drug treatments.
Complications
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Arrythmias
Stroke
DVT/PE
Malabsorption
Hepatic congestion
Muscle wasting
Angela Graves MSc BSc RN
Heart Failure Nurse Manager/Nurse Practitioner
East Lancashire Heart Failure Nursing Service
East Lancashire Hospitals NHS Trust
The impact of heart failure
• The National Heart Failure Audit Report (2010) suggests
that heart failure affects one in every hundred here in
the UK with this figure rising steeply for those over 75
years to 7%.
• Cost to the National Health Service of heart failure is
approximately £625 million, predominantly due to
emergency admissions.
• NICE (2010) argue that with appropriate diagnosis,
treatment and management morbidity and mortality can
be greatly improved.
Prognosis
• Prognosis is poor on the whole, with approximately 50%
of people with heart failure dying within four years of
diagnosis. Within a year of admission to hospital 32% of
patients will die
• The mortality rate in the UK appears to be improving. A
UK study found that the six-month mortality rate for
people with heart failure had improved from 26% in 1995
to 14% in 2005.
• The prognosis for people with heart failure and
preserved left ventricular ejection fraction is a little
better than the prognosis for people with heart failure
and reduced ejection fraction.
ELHT Heart Failure Nursing ServiceWhat we offer
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The Link from Primary to Secondary Care
Review of patient as in patient
Community Clinics
Optimisation of medication
On going management and support
Limited home visiting service
Patients in end stage heart failure
Supportive Services
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Heart Failure Nursing Service
Cardiac Rehabilitation Teams
Community Matron/District Nursing
Palliative Care Teams- Hospice services,
Case Study 1
• 35 year old Mr Y attends for review; he first
consulted you with flu symptoms approximately
8 weeks ago. He says his symptoms are getting
worse; his exercise capacity has been markedly
reduced, is orthopneic, and is complaining of
weight gain particularly in relation to his
abdomen. You order routine bloods and find
deranged LFTs, what are your next steps in this
management of this patient?
Answer - Case Study 1
• Full bloods U/Es, egfr, LFTs, FBC, Thyroid
function, Pro BNP, ESR, CRP
• ECG
• ECHO
• Cardiology Review does he require hospital
admission
• CXR
• Support network Pumping Marvellous
Case Study 2
• Mrs V aged 85 yrs, is reviewed at home, which is
a home for the elderly, she has a history of IHD
and recent ECHO you ordered has shown an LVEF
of 35%. She experiences no chest pain, but has
increasing shortness of breath, mild peripheral
oedema, and is currently taking statin, aspirin,
Atenolol 25mg, and Ramipril 1.25mg. What
medication would you initiate and referrals
make?
Answer – Case Study 2
• Managed by the practice
• Review of medication, switch to appropriate
Beta Blocker
• Up to date bloods look to titrate ACE
• Introduction of loop diuretic
• Education to staff in the home- what to look out
for
• PPC what does Mrs V want