New NICE Heart Failure Guidelines What do they mean for primary and secondary care, and patients?

Transcription

1 New NICE Heart Failure Guidelines What do they mean for primary and secondary care, and patients? Prof Ahmet Fuat PhD FRCGP FRCP PG Dip (Cardiology) GP & GPSI Cardiology Darlington Professor of Primary Care Cardiology Durham University President Primary Care Cardiovascular Society

2 Plan Previous guidelines NICE 2018 Quality standards Local HF clinic data Areas of non-compliance Future developments

3 Chronic heart failure Implementing NICE guidance September 2018 NICE clinical guideline 106

4 Background The National Institute for Health and Care Excellence (NICE) published an update to the Chronic heart failure in adults: diagnosis and management on 12 th September The NICE guidelines are primarily aimed at primary care and include recommendations for diagnosis, lifestyle, therapeutic and device management. They replace clinical guideline 108 (CG108) which was published in August

5 HF multidisciplinary team Specialist HF team Physician, HFNS, Pharmacist - Diagnose HF (type) - Inform patient - Treat + titrate - Manage HF not responding to treatment Wider team Rehabilitation, palliative care, devices etc

6 Diagnosis Switch from BNP to NTproBNP for primary care No change in NT probnp thresholds (400 pg/ml) If raised, specialist + echo Speed of referral guided by NT probnp level 2ww for urgent (NTpBNP>2000) vs 6 weeks Remove the urgent referral if previous MI Extended consultation Review within 2w

7 LEFT VENTRICULAR WALL STRESS TISSUE VENTRICULAR INDUCES NEW BNP SYNTHESIS Pro-BNP 77 N-terminal Pro-BNP 76 BNP CIRCULATION H 2 N- 32 a.a. CYS CYS PHE GLY BNP ASP ARG ILE COOH- GLY LEU GLY SER

8 BNP: Quantitative Marker of HF Volume Pressure ANP Suppression of renin-angiotensin and endothelin CNP BNP = Decreased peripheral vascular resistance (decreased blood pressure) LV Diastolic Dysfunction + LV Systolic Dysfunction + Valvular Dysfunction + RV Dysfunction Increased natriuresis Iwanaga Y. et al. JACC 2006; 47:

9 NP cut-offs ESC (2016) - different levels for acute + chronic NICE (2018) - single cut offs for acute and chronic ESC Chronic HF cut-off BNP = 35 pg/ml NTP = 125 pg/ml Acute BNP = 100 pg/ml NTP = 300 pg/ml NICE Chronic HF cut-off NTP = 400 pg/ml

10 The problem : NT-proBNP and age

11 Age-dependent values of NT probnp for ruling out heart failure are superior to a single cut-point for ruling out suspected systolic dysfunction in primary care (ICON- PC) Hildebrandt P, Collinson PO, Doughty RN, Fuat A et al Eur Heart J 2010; 31: To investigate age-dependent rule out values in patients in primary care setting with symptoms suggestive of heart failure, to compare these with present standards and to investigate the influence of gender and vasoactive treatment Ten published and unpublished studies of 5508 patients in primary care who had NT-proBNP measurement performed plus echocardiographic estimation of ejection fraction were identified and analysed.

12 Group (cut off) n Sensitivity Specificity NPV A: Proposed age related % (95% CI) % (95% CI) % < 50 year (50 pg/l) ( ) 57.2 ( ) years (75 pg/l) ( ) 51.0 ( ) 96.8 > 75 years (250 pg/l) ( ) 53.7 ( ) 92.4 C: 2008 ESC Guidelines (Age independent (< 400 ng/l)) < 50 year (400 pg/l) ( ) 97.1 ( ) years (400 pg/l) ( ) 90.6 ( ) 93.5 > 75 year (400 pg/l) ( ) 67.1 ( ) 91.4

13 Conclusions NT-proBNP must now be regarded as having hard evidence and sufficient data to be implemented as a an initial test for the presence of significant LV systolic dysfunction in patients with symptoms arousing clinical suspicion of heart failure Further diagnostic tests such as echocardiography could be reserved for patients with elevated levels or continuing strong suspicion of heart failure. Using age-dependent rule out values will optimize the diagnostic accuracy, minimise the risk of a missed diagnosis of heart failure and rationalise echocardiographic follow-up. Cut-off levels of 50 pg/l (age <50 years), 75 pg/l (50-75 years) and 250 pg/l (>75 years) can be recommended as optimised rule out thresholds.

14 NT probnp Age Dependent Thresholds based on Hildebrandt P, Collinson P, Fuat A et al EHJ 2010;31: Age < 60 years Age years Age > 75 years Raised levels >50pg/ml >100pg/ml >250pg/ml High levels >450pg/ml >900pg/ml >1800pg/ml

15 Treatment No change in medication / devices B-Blocker + ACEi / ARB for all HFrEF MRA for HFrEF if remains symptomatic Sacubitril/Valsartan 4th line Exercise based rehab when stable (flexible + psychological) Do not routinely restrict salt + water

16 Communication Care plans for all patients Shared with patient (carers), medical + nursing Across primary and secondary care Diagnosis Treatment Medication, device, rehab etc Social and care needs (including carers) What to look for if problem Who to contact (HFNS)

17 Primary care team Take over care when clinically stable 6 monthly review Communicate Access specialist services as needed

18 Research priorities Diuretic regime in advanced HF Optimum imaging strategy (CMR + others) AF and BNP threshold CKD and BNP threshold Risk tools for predicting sudden cardiac death

19 7 Quality Standards (OP) Diagnosis with echo + specialist assessment Seen within 2 weeks if NP level very high If HFrEF ACEi / Beta-blocker Review within 2 weeks if medication changed 6 monthly review of stable patients Offered exercise-based rehabilitation (Developmental) flexible programme (OOH, home based etc)

20 9 NICE Quality Standards (IP) Single measurement of BNP if HF new HF suspected Echo within 48 hours if BNP raised Specialist HF team (ward + outreach) All patients have early + continued input from HF team If taking B-B, continue unless problem Start / restart B-B before discharge Start ACEi / ARB + MRA before discharge Stable for 48 hours before discharge FU within 2 weeks of discharge

21 What s new Increased focus on the role of a core specialist team (MDT) working in collaboration with the primary care team 1. 6 monthly follow up in primary care to ensure better outcomes for heart failure patients 1. Measure N-terminal pro-b-type natriuretic peptide (NT pro-bnp) in people with suspected heart failure including this with previous MI 1. Increased information provision to patients with heart failure to allow better understanding of the options and uncertainties of their condition 1. MRAs should be offered to patients symptomatic on ACEi/ARB and BB 1. Primary care clinicians are able to initiate. Patients who have had an MI should have an NT pro-bnp test prior to referral for echocardiogram 1.

22 Conclusion Not much that s new or controversial!

23 HF clinic DMH Established 2002 Professor Fuat + Professor Murphy/SHFNs Included BNP / NT probnp Also clinics at BAH / UHND Local primary and secondary Care Referral guidelines Local HF clinic data

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25 BAH/DMH HF clinic 100% 75% HF N 50% 25% %

26 Final diagnosis HFPEF Not HF HF Alt Cause Poss HFPEF Mixed HFPEF & Other DNA HF Rig HF Pos Mix No 713

27 CMR or not? 100% 99 75% % CMRI N % 386 0% HFPEF HFREF

28 Heart Failure Clinic Discharge Template Dear Doctor, This patient has been seen and completed their diagnostic and management work up in the Darlington Integrated Heart Failure Service. Diagnosis mild, moderate or severe LVSD/HFPEF/LVDD/VHD etc NYHA Class at diagnosis: NYHA Class at discharge: Investigations Undertaken: Relevant Bloods (BNP, Renal function) - ECG - Chest X-ray - Echocardiogram - Cardiac MRI - Other - Current Medications: (dose and reason maximum dose not achieved) Diuretic - Beta-blocker - Ace inhibitor (or ARB) - Mineralocorticoid antagonist (MRA) - Other relevant drugs (Please remind patient that if diarrhoea, vomiting or any illness that may cause dehydration the patient should stop diuretic, ACEi, ARB and MRA until drinking and eating again. Restart at usual dose) CRT and or ICD Please see this patient every X months in your CHD/HF clinic If deterioration in HF please refer back to specialist heart failure nurse in the community or the HF clinic urgently Yours sincerely,

29 Prognosis in Heart Failure P =0.003 (95.0% Confidence Interval )

30 Areas for development Pharmacist input Increase capacity (or reduce referrals) to provide urgent + 6 week routine slots Care plans Develop primary care teams NT probnp titration protocol (?) Expand rehabilitation

31 Other areas 7 day service for HF Community IV diuretics home or lounge S/C furosemide Inpatient HF review Structured review (wherever delivered)

32 Any further questions... ahmetfuat nhs.net