Transcript Heart Failure - Derby GP Specialty Training Programme

Dr My Leg/Legs Are Swollen…


Dr Rashmi Gaekwad
RDH 20th April 2011
Foot, leg and Ankle swelling--Causes
Heart Failure
Liver Failure
Renal Failure
DVT, CVI, Varicose Veins, Surgery, Lymphoedema
Starvation, Malnutrition, Insect Bite/Sting, Burns
Obstruction
Hormones-oestrogen (OCP,HRT)/Testosterone
Calcium Channel Blockers- Nifedipine, amlodipine, Diltiazem, Felodipine,
Steroids, NSAIDs
Antidepressants- MAO Inhibitors, Tricyclics (Amitry, Nortr, Desipramine)
How are you going to explain it to
your patients?












The Heart Pumps blood through the arteries under high
pressure.
This pressure is lost and blood relies in simple back
pressure to move to the heart.\This ia aided by muscle
activity, squeezes the veins and pushes blood along.
When muscle movement is lost, it is harder to get the
blood back up from the legs.
Water Seeps from distended veins into surrounding tissues
and legs and feet swell.
Repeated episodes of swelling , veins become more leaky.
One way valves in the veins are collapsing under the weight
of all the blood, pooled on top of them
The swelling gets worse
Complications:
Needles and pins sensation-poor microcirculation
Lousy circulation causes blood to clot
Clot can impede circulation
Break loose-travel to the Brain-Stroke, Lungs- Pulmonary
Embolus,
Heart Failure




Causes:
High Output-Hyperthyroidism, Anaemia, AV Mal
Low Output-Preload, Pump Failure, After load
RHF-PHTN,TR
BACKGROUND

Complex syndrome caused by impaired cardiac function

Two types: left ventricular systolic dysfunction (LVSD) and heart failure with
preserved ejection fraction (HFPEF)

Most common cause: coronary artery disease

30–40% of patients die within a year of diagnosis


Prevalence
Around 900,000 people in the UK, average age-76yrs

expected to rise in the future

GP HF register-average 10 pts new diagnosis, 30pts per GP
Symptoms/Signs



LVF-SOB,NOCTURAL COUGH/WHEEZE, LETHARGY/FATIGUE, <EXERCISE
TOLERANCE
RVF-OEDEMA, NAUSEA/ANOREXIA,FATIGUE/WASTING, ABDO DISCOMFORT
SIGNS-TACHYOPNEA,TACHYCARDIA, MUSCLE WASTING, >JVP,HEPATOMEGALY,
ASCITES.BASAL- CREPITATIONS, EFFUSIONS, WHEEZE.CARDIOMEGALY, PULSUS
ALTERNANS.
Diagnosis
In patients with symptoms and signs of heart failure:
Measure serum natriuretic peptides in patients without previous MI
Refer to have transthoracic Doppler 2D echocardiography
and specialist assessment within 2 weeks if
previous MI
BNP > 400 pg/ml or
NTproBNP > 2000 pg/ml




Refer to have transthoracic Doppler 2D echocardiography and specialist assessment
within 6 weeks if:
BNP 100 – 400 pg/ml or NTproBNP 400 – 2000 pg/ml
If BNP < 100 pg/ml or NTproBNP < 400 pg/ml, heart failure is unlikely in an
untreated patient
BNP-Raised in LVH, PE, Renal Dysfunction, Sepsis, COPD, >70yrs, Cirrhosis, DM
When to refer to the specialist MDT

for the initial diagnosis of heart failure

for the management of severe heart failure (NYHA class IV)

heart failure that does not respond to treatment

heart failure that can no longer be managed at home

when they are planning a pregnancy or are pregnant

when they have heart failure due to valve disease

Co-morbidities that may impact on HF(COPD, RF, PVD,Gout,Anaemia)

Angina, AF, Symptomatic Arrhythmias
Mgmt-non drug measures







Patient -educate, Rx, prognosis, written plan-Self-care confidence, maintenance & management
Diet-low salt adequate calories, restrict alcohol, loose weight if obese
Restrict fluid intake in severe HF
Lifestyle measures: Smoking cessation, regular exercise
Vaccination: Influenza (yrly) and Pneumococcal (once)
Air Travel-depend on their clinical condition
Assess for depression
Mgmt-pharmacological
Offer both ACE inhibitors and beta-blockers licensed
for heart failure to all patients with LVSD
Offer beta-blockers licensed for heart failure to all
patients with LVSD, including older adults and pts with





peripheral vascular disease
erectile dysfunction
diabetes mellitus
interstitial pulmonary disease
COPD without reversibility
Seek specialist advice and consider adding one of the following if patient remains symptomatic despite optimal therapy with an
ACE inhibitor and a beta-blocker:

aldosterone antagonist licensed for heart failure (especially in NYHA class III–IV or MI in past month)

ARB licensed for heart failure (especially in NYHA
lclass II-III)

hydralazine in combination with nitrate (especially in people of African or Caribbean origin with NYHA
class III-IV)
Digoxin-AF+HF
Anticoagulation-Thromboembolism, LV aneurysm
Aspirin-Atherosclerotic arterial disease (CHD)
Statins, Amiodarone, Spironolactone,
Monitoring/Rehab
All patients with chronic heart failure require monitoring. This
monitoring should include:
 a clinical assessment of functional capacity, fluid status,
cardiac rhythm (minimum of examining the pulse), cognitive
status and nutritional status
 a review of medication, including need for changes and
possible side effects
 serum urea, electrolytes, creatinine and eGFR
When a patient is admitted to hospital because of heart failure,
seek advice on their management plan from a specialist in
heart failure
Offer a supervised group exercise-based rehabilitation programme
designed for patients with heart failure
Case 1





86 year old Mr DF presented to his GP with cough/sputum, SOB, swelling of his legs, unable to
sleep well at night for 2 weeks. He had a h/o fall and has been c/o chest pain, right shoulder pain.
BG-had THR ®, Lives with his wife, quite independent., never smoked
Meds-Lactulose, Simvastin, omeprazole, Aspirin.
O/E- temp of 37.4,sats-94% bi-basal crackles, pedal oedema
How would you manage this patient?
Case 2





Home visit –Mrs MF 68 yrs old -swelling of legs, decreased mobility and sore creases
for 3 weeks. Poor sleep. Not taking her medications regularly for 3/52.Difficulty in
doing her ADLs, sleeping downstairs.
BG-Lives alone, independent, PD
Meds Quetiapine, Rasagiline, Sinemet-Plus.
O/e-large built lady, Obs-stable, oedema-ankles and legs, under arms, groin and inframammary regions-excoriated , inflamed, gait-short steps.
How would you manage this patient?
Lighter moments….