Transcript Heart Failure Presentation - Dorset County Hospital NHS

Chronic Heart Failure
GP Clinical update 11/11/09
Dr Paul Armitage
GP Heart Failure Specialist, Dorset PCT
Tracey Dare
Heart Failure Nurse Specialist, DCH
Chronic Heart Failure
“There is no disease that you either have or
don’t have – except perhaps Sudden Death
or Rabies. All other diseases you either have
a little or a lot of”
Geoffrey Rose
Chronic Heart Failure- setting the
scene
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Common
Costly
Disabling
Deadly
Increasing
1-2%of the population
1-2% of NHS budget
symptoms have large impact on quality of life
mortality 30% at 12 months but improving steadily
ageing population/more effective treatment for CHD
What is Heart Failure – key facts
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Heart Pump Inefficiency – either primarily a
disorder of filling or of emptying (Tinsley R
Harrison, 1950)
Most common cause is LV muscle damage
Various conditions may predispose to, or
cause, such muscle damage
Guess who?
Causes of Chronic HF (UK only – Fox
et al, European Heart Journal 2001)
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Coronary Heart Disease
Chronic hypertension
Idiopathic
Valvular dysfunction
Cardiac arrhythmias
Alcohol
Other
Undetermined
52%
4%
13%
10%
3%
4%
4%
10%
Prevalence
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CHD increasing
Ageing population
Better CHD acute phase care
Better CHF management
West Dorset Population - prevalence
estimate 4,500 (sex & age specific
calculations, 2002)
Incidence
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1- 4 new cases per 1000 population each year
Incident rate rises to more than 10 cases per 1000 in
those aged 85 years and over
Male:female = 2:1
West Dorset population - incidence estimate 330
new cases per year (sex & age specific calculations,
2002)
Guess who ?
Mortality
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Mild – moderate CHF – 20% at 1 year
Severe - >50% at 1 year
Survival all classes – 30% at 8 years
80% mortality in men within 6 years of
diagnosis
Class II – sudden death risk
Health Service Use
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HF accounts for 5% of all hospital
admissions
Patients frequently admitted
Bed occupancy average 20 days each
admission
£360 million (hospitalisations = 59.5%)
Guess who?
Why so difficult?
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Symptoms non-specific
Clinical signs insensitive
Definition of heart failure disputed
Poor primary care access to cardiac
investigations eg BNPs and
echocardiography
Conditions presenting with similar
symptoms
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Obesity
Chest disease
Venous insufficiency in lower limbs
Drug induced ankle swelling (calcium channel blockers)
Drug induced fluid retention (NSAIDs)
Hypoalbuminaemia
Intrinsic renal or hepatic disease
Pulmonary embolic disease
Severe anaemia or thyroid disease
Bilateral renal artery stenosis
Symptoms – may not be terribly helpful!
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Shortness of breath on exertion
Decreased exercise tolerance
PND
Orthopnoea
Ankle swelling
Guess who?
Clinical signs
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The most specific signs are:
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Laterally displaced apex beat
Elevated JVP
3rd heart sound
Less specific signs:
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Tachycardia
Lung crepitations
Hepatic engorgement
Peripheral oedema
Investigations
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12 lead ECG
Chest X-ray
FBC, U&E, TFT, LFT, glucose, lipids, urinalysis, peak
flow
BNP where available
Echocardiography (open access available locally)
NB: If ECG is normal - it is very unlikely that the
diagnosis is heart failure. Same for BNP
Guess who?
How useful is BNP?
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96% as useful as a panel of cardiologists
NB CTR on CXR is only 79% as useful as a
panel of cardiologists
(the gold standard was an expert panel
diagnosis blinded to BNP results)
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Lancet 1997; 350:1349-53
To diagnose Heart Failure
3 things are essential:
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1. Patient
2. BNP
3. ECHO
Awaiting new NICE guidelines
(PCTs beware!)
Guess who?
CHF management
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Establish cause (angiography, CDM screen) and
treat appropriately
Evidence based pharmacological treatments (ACEi,
Beta blockers, aldosterone antagonists)
Device therapy (CRT-P, CRT-D)
Self management/ lifestyle advice
Heart Failure Services
Liaison/ onward referrals (CKD team, PPM techs,
arrhythmia nurse, Smoke Stop, Dieticians, Cardiac
Rehab, pharmacists, Community Matrons, PC Team)
ACE inhibitors
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HOPE = Heart Outcomes Prevention Evaluation
Study
CONSENSUS = Co-operative North Scandinavian
Enalapril Survival Study
SOLVD = Studies of Left Ventricular Dysfunction
All grades of CHF unless specific contraindications
Cautions
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Significant renal dysfunction, bilateral renal artery stenosis,
symptomatic/ severe asymptomatic hypotension, K+
supplements/ K+ sparing diuretics
ACE inhibitors
ACEi
Starting dose
Target dose
Ramipril
2.5mg od
10mg od
Lisinopril
2.5 – 5mg od
30-35mg od
Enalapril
2.5mg bd
10-20mg bd
Cardio-selective Beta blockers
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Undisputed evidence. Recommended in
NICE guidelines
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Reduction in HF exacerbations
Reduction in hospitalizations and bed days
Improved symptoms/ NYHA class/ QOL
Reduces mortality
Beta blocker Trials
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CIBIS (1994) and CIBIS II (1999) (The Cardiac Insufficiency
Bisoprolol Study)
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COPERNICUS (CarvedilOl ProspEctive RaNdomIzed
Cumulative Survival) 2001
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CAPRICORN (Effect of Carvedilol on outcome after myocardial
infarction in patients with left ventricular dysfunction) 2001
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SENIORS (Study of the Effects of Nebivolol Intervention on
Outcomes and Rehospitalisation in Seniors with heart failure)
Undisputed evidence from various studies
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Beta blockers
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Beta-blocker titration
Bisoprolol 1.25mg, 2.5mg, 3.75mg, 5mg,
7.5mg, 10mg
Carvedilol 3.125mg BD, 6.25mg BD,
12.5mg BD, 25mg BD
Nebivolol 1.25mg, 3.5mg, 5mg, 7.5mg,
10mg
Aldosterone antagonists
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Consider for moderate to severe HF already on ACEi
and loop diuretic
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Spironolactone 25mg (increase to 50mg if necessary)
Epleronone 25mg (increase as above)
NB licensed for post MI only but consider for all patients if
Spironolactone causes hormonal side effects
NB Renal function monitoring
Other pharmacological considerations
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Co-morbidities/ polypharmacy
Compliance and understanding
Blister packs
Timely interface communication of drug dose
changes
Heart Failure Service
Dorset County Hospital
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Set up in response to NSF 2001
Aim to optimise pharmacological therapy through
series of out patient visits
Patient education (BHF Heart Failure Plan).
Medication concordance and treatment compliance.
Monitoring
Support & point of contact
Interface link. Onward referrals
Heart Failure Service
Dorset County Hospital
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Clinic based intervention only
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x1 Full time HF Nurse Specialist
GP Heart Failure Specialist x2 sessions per week
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Service provision includes:–
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Dorset County Hospital (x2 per week, plus some in-patient
cover dependant on availability)
Weymouth (x2.5 per week)
Bridport Community Clinic (x1 per week)
Heart Failure Service
Dorset County Hospital
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Service population 229,836
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Estimate 4,500 prevalence and 330 new patients per
year
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Total referrals up to end of year 8 = 1489 (187 per
year)
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301 patients on present active caseload (as of
3/11/09)
Heart Failure Service
Dorset County Hospital
Total number seen
Combined HFNS & GPHFS Contacts
1600
1400
1200
1000
800
600
400
200
0
Series3
Series2
Series1
1
2
3
4
5
Year
6
7
8
Heart Failure Management
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Complex condition to manage
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Timely recognition/ diagnosis/ treatment of underlying causes
results in best outcomes and more cost effective in the long run
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Open access echo service – direct route of referral to the HF
service
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Pharmacological therapy is only part of the management but a
big part of the heart failure service work
Heart Failure Service
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Referrals from GPs can be accepted if the patient already has a
confirmed diagnosis and previously known to Cardiology
Consultants
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Open access ECHOs – if heart failure confirmed this will result
in direct referral to the service for assessment/ further
investigations and formulation of management plan
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Limited service provision (no domiciliary service) but willing and
happy to help where we can. To discuss any patient on an
individual basis – please contact us via Dorset County Hospital
01305 255610 (24 hour voicemail) [email protected]
Q. Why are they no longer with us?
Answers:
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1. Late diagnosis
2. GP didn’t have access to BNP or Heart
Failure Services
3. Beta blockers not available in Chechnia
4. Too much cocaine/ alcohol