Heart Failure. Optimising treatment and balancing co-morbidity in the community. Andrew Ludman Cardiologist

Transcription

1 Heart Failure Optimising treatment and balancing co-morbidity in the community Andrew Ludman Cardiologist

2 What is heart failure? A structural cardiac abnormality leading to failure of the heart to provide adequate oxygen to metabolising tissues despite normal filling pressures. A syndrome in which patients have typical symptoms (e.g. breathlessness, ankle swelling, and fatigue) and signs (e.g. elevated jugular venous pressure, pulmonary crackles, and displaced apex beat) resulting from an abnormality of cardiac structure or function. Acute Chronic Hospitalised De novo Decompensated Right Left 2012 ESC HF guidelines

3 What is heart failure? Heart failure with reduced ejection fraction (HFREF) Heart failure with preserved ejection fraction (HFPEF)

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5 Epidemic of Heart Failure?

6 Cardiovascular Disease in the UK BHF CVD Statistics Compendium 2017

7 Prevalence of HF in the UK ~550,000 people in the UK with heart failure Roughly static QOF 0.8% BHF CVD Statistics Compendium 2017 Bhatnager et al Heart

8 Heart failure mortality is probably decreasing Death registration data for: England , population 52 million people Oxford , population 2.5 million people 2015 Rahimi et al. J Epidemiol Community Health

9 1 year HF mortality in clinical trials (HFREF)

10 Mortality in community diagnosed HF Scottish GP practices 10,309 new HF diagnoses Heart failure % alive Male Female 30 days year years Mamas et al. EJHF

11 Hospitalised heart failure and mortality in UK ACALM registry of Northern England 929,552 hospitalised patients 2000 to yrs follow up AF: 31,695 HF + SR: 20,768 HF+ AF: 10, Ziff et al. Int J Card

12 Increasing inpatient episodes for heart failure BHF CVD Statistics Compendium 2017

13 Co-morbidity is (almost) universal Systems/Statistics-Trends-and-Reports/Chronic- Conditions/Downloads/2012Chartbook.pdf

14 What s new in the 2018 Chronic HF NICE guidance? 38 page summary 520 page full version Aims to be patient focussed but has some controversial areas

15 Diagnosis Algorithm NICE Chronic Heart Failure Guideline 2018 BMJ 2018;362:k3646

16 Treatment Algorithm NICE Chronic Heart Failure Guideline 2018 BMJ 2018;362:k3646

17 Roles of the Specialist MDT and Primary Care BMJ 2018;362:k3646

18 Complex patient journey requires lot s of communication Extended first specialist appointment Early follow up (~2 weeks) Sensitive and tailored discussion Early input from palliative care Clinical updates in both directions Where is your patient on this trajectory? Individualised care plan

19 Other changes to note Salt and water restriction are out egfr 45 and 30 marked as thresholds to be more careful with drug initiation (but limited evidence for this) Aiming for triple therapy for HFREF unless absolutely no symptoms Offer rehabilitation programme

20 Top Tips in HFREF Teach the patient to use weight diary First thing in the morning, post voiding, same clothes Start low and go slow does not mean taking 1 year to introduce medications Aiming for ACE-I, BB and MRA Generally ACE-I first but if particularly tachycardic then BB Edge both up every 2 weeks Renal function and BP check each time Early referral for investigation of reversible causes

21 Top Tips in HFPEF Teach the patient to use weight diary First thing in the morning, post voiding, same clothes Normalise what you can BP Heart rate Heart rhythm HbA1c Alcohol Spironolactone can be excellent for fluid, symptoms and BP If unexpected LVH or unclear cause early referral

22 Top Tips in Right heart failure Don t assume based on clinical features only Fluid balance, fluid balance, fluid balance! Avoid the downward spiral No evidence for ACE-I or BB so consider stopping Spironolactone may be a good option again May require thiazide diuretic (BDF or metolazone) Investigate and treat cause as early as possible Optimise respiratory disease Sleep apnoea? Chronic PE? ASD?

23 Top Tips for renal function Renal function checks in stable patients 1-2 weeks after dose changes Monthly for 3 months 6 monthly after this Generally need minimum 2 measures to assess trajectory Diuretics increase Ur/Cr through haemoconcentration not necessarily a change in renal function ACE-I/ARB allow up to 30% increase in Cr Check not too dry Stop non-prognostic BP meds Limited role for ACE-I/ARB/MRA in HFPEF

24 Interpreting NTproBNP results in people with suspected acute heart failure Negative predictive value 0.98 Positive predictive value 0.80 Negative predictive value 0.88 Positive predictive value 0.8 to 0.94 ng/l HF excluded HF very unlikely HF unlikely* HF likely in patients <50 years HF likely in patients <75 years HF very likely in all patients *see text Andrew Ludman 2018 age and renal function = NTproBNP

25 Diabetes and heart failure a good new option Don t start if egfr <60 Stop if egfr drops <45 Caution regarding diuretics and fluid balance Increased urinary infections BUT Reduces HF hospitalisation by up to 50% Ongoing work to refine optimal group and mechanisms Singh DOI: / Zinman B et al. N Engl J Med 2015;373:

26 Sacubitril/Valsartan A new twist on an old drug 20% reduced risk of CV death or first HF hospitalisation (ARR=4.7%) 20% reduced risk of CV mortality (ARR=3.2%) 21% reduced risk of first HF hospitalisation (ARR=2.8%) Fewer HF symptoms and a better quality of life* 1. McMurray J, et al. N Engl J Med. 2014;371: Packer M, et al. Circulation 2015;131:54 61

27 Sacubitril/Valsartan A new twist on an old drug Neurohormonal activation in heart failure Sympathetic nervous system Natriuretic peptide system NPRs Natriuretic peptide receptors Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy NPs Natriuretic peptides Epinephrine (adrenaline) Norepinephrine (noradrenaline) α 1, β 1, β 2 receptors Vasoconstriction RAAS activity Vasopressin Heart rate Contractility Renin-angiotensin-aldosterone system Ang II AT 1 R Vasoconstriction Blood pressure Sympathetic tone Aldosterone Hypertrophy Fibrosis Ang=angiotensin; AT 1 R=angiotensin II type 1 receptor; NPs=natriuretic peptides; NPRs=natriuretic peptide receptors; RAAS=renin-angiotensinaldosterone system. 1. Levin E, et al. N Engl J Med. 1998;339: Nathisuwan S, Talbert RL. Pharmacotherapy. 2002;22: Kemp CD, Conte JV. Cardiovascular Pathology. 2012; Schrier RW, Abraham WT. N Engl J Med. 2009;341:

28 Sacubitril/Valsartan A new twist on an old drug NICE Technology Appraisal Guidance (TA388): Sacubitril/valsartan is recommended as an option for treating people with HF with reduced ejection fraction, only in people: 1 with NYHA class II to IV chronic heart failure and who are already taking a stable dose of ACEI or ARBs and with a left ventricular ejection fraction of 35% or less 1. NICE Technology Appraisal Guidance (TA388). Appraisal consultation document. Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction. April 2016 Available at: Last accessed 27 April 2016

29 Top Tips for Sacubitril/Valsartan No such thing as mild severe LVSD Outcomes are still not good Why not offer recommended optimisation of treatment? Locally has been extremely successful Anecdotally Better symptoms Less diuretics No age cut off Generally not advised with egfr <30 Does require HF cardiologist initiation currently

30 Conclusion New NICE guidelines for chronic heart failure are useful to help define healthcare roles and continue to try and increase pressure to improve services to improve outcomes Heart failure outcomes are improving but they are still not good Heart failure cardiologist plays a key role in early confirmation of diagnosis and investigation Fluid balance is crucial for any type of heart failure Treating co-morbidities will help the heart New investigations, drugs and devices available and more coming

31 Heart Failure Optimising treatment and balancing co-morbidity in the community Andrew Ludman Cardiologist