Heart Failure in 2012 with reference to NICE Guidance Dr Maurice Pye Consultant Cardiologist York District Hospital

Transcription

1 Heart Failure in 2012 with reference to NICE Guidance 2010 Dr Maurice Pye Consultant Cardiologist York District Hospital

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4 A little over elaborate,do not include ECG or CXR If clinical suspicion is high (or( any h/o MI) ) refer for an echocardiogram or consultant cardiology opinion If uncertain then ECG,Chest X ray + BNP are reasonable if all normal then not heart failure! BNP very good rule out test - ie few false negatives if its not raised then unlikely heart failure but non specific ie fair no of false positives raised in COPD, cor pulmonale,, AF, valvular heart disease, renal disease, sepsis, LVH, diabetes UNLESS Very high

5 NEW 2 week referral guide for secondary care If BNP vey high If any history of Myocardial Infarction

6 CXR in the diagnosis of heart failure: Cardiothoracic ratio > 50% is specific, not sensitive Useful to exclude other causes of SOB

7 ECHO in the diagnosis of heart failure: Best test for assessment LV systolic dysfunction Of those on HF treatment only 25% have significant LV Only 25% referred from 1 o care have LV systolic dysfunction Only 8%? New heart failure had LV systolic dysfunction?diastolic dysfunction and heart failure

8 Perform Perform transthoracic Doppler 2D echocardiography to exclude important valve disease, assess systolic (and diastolic) function n of the (left) ventricle, and detect intracardiac shunts. Ensure that: echocardiography is performed on high-resolution equipment by experienced trained operators (+- contrast echo) demand does not compromise quality those reporting echocardiography are experienced in doing so. - When a poor image is produced by transthoracic Doppler 2D echocardiography, consider other imaging methods, such as radionuclide angiography, cardiac magnetic resonance imaging or transoesophageal Doppler 2D echocardiography.

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10 Establish diagnosis of what type of heart failure Exclude following as as mimickers of irreversible or fixed LV dysfunction Significant valvular heart disease esp MR or AS Dysrhythmias AF tachycardiomyopathy Ischaemia Alchohol Catecholamines - Phaeochromocytoma Hereditary cardiomyopathies Pericardial disease

11 Life style alchohol abstinence best, smoking cessation, Exercise and rehab with educational component for patient to manage his condition Aspirin for patients with IHD only Warfarin if in AF very strong indication some patients with SR Depression/ anxiety common often need treatment in their own right

12 Other general measures for heart failure Risk factor management obesity hypertension Salt reduction( 3g/day) Avoid Calcium antagonists, NSAIDs,, Anti-arrhythmics Other Flu vacc, Pneumococcal vacc

13 Drug treatment of Heart Failure Diuretics usually loop diuretic frusemide or bumetamide ACE inhibitor eg generic ramipril Or Angiotensin 2 blockade generic losartan ONLY IF true allergy to ACE or definite ACE cough (very rarely combined) Or hydrallazine +- nitrate if intolerant to both OR African/Caribbean

14 Drug treatment of Heart Failure 2 Beta blockers uptitrate weekly when euvolaemic Spironolactone/Eplenerone (Aldosterone antagonists) Monitor Creatinine/Potassium weeks post Digoxin still can be useful even in SR obviously quite narrow therapeutic window CRT Bi Ventricular Pacing +-+ ICD therapy DEVICE THERAPY CRT

15 Lives saved with Rx in LV failure TRIAL Lives saved/1000/year HOPE ACE in IHD <1 SOLVD-P ACE in LVSD 7 SOLVD-R ACE in low EF 17 MERIT CIBIS Beta B in LVSD 38 Beta B in LVSD 42 RALES Spironolactone 52 COPERNICUS BB severe LV 70

16 The 1 st large major study of Ivabradine V placebo = Beautiful Study NEGATIVE no benefit The 2 nd study = SHIFT study showed NO effect on mortality but significantly reduced hospital admissions for heart failure So perhaps could consider this drug in more severe heart failure if beta blocker contraindicated or could not get to reasonable dose of bisoprolol ie 5 mg AND HR still > 70 /min and no BiV pacing