The Patient Journey through Heart Failure Primary Care Handout

Transcription

1 The Patient Journey through Heart Failure Primary Care Handout Dr Ameet Bakhai Consultant Cardiologist Background Observed 5 year survival rates for heart failure patients are 26-52% worse than many common cancers (REF). There are two stages for patients related to heart failure those with a suspected diagnosis under investigation and those with an established diagnosis. PREDICTION OF HEART FAILURE 1. Patient with the following CHRONIC factors may be predicted to be at risk of developing heart failure: The MESA study predicted that over 5 years, the patients most likely to develop heart failure are those who are male, smokers, with advanced age, obesity, diabetes, raised blood pressure and resting heart rate and high blood assay levels of NT-proBNP assay (REF 2). Additional predictors also include a past history of ischemic heart disease, rheumatic fever, anaemia and excess alcohol intake. Royal Free London NHS Foundation Trust Consultant Cardiologist Barnet Hospital R&D Clinical Deputy Director Heart Function Improvement Lead Barnet Schwartz Round Clinical Lead Barnet European Society of Cardiology ESC Fellow & Member of the Heart Failure Association & Hypertension Society NHS England (London Region) End of Life Care Clinical Leadership Group Member NICE External Reference Group abakhai@nhs.net Phone: (Varsha) Fax: Dr Ameet Bakhai, MBBS, MD, FRCP, MESH, FESC Excellence in patient care, heart care, research, health economics, commissioning and quality.

2 REFERENCES Askoxylakis V, Thieke C, Pleger ST, et al. Long-term survival of cancer patients compared to heart failure and stroke: A systematic review. BMC Cancer. 2010;10:105. doi: / Chahal H, Bluemke DA, Wu CO, McClelland R, Liu K, Shea SJ, Burke G, Balfour P, Herrington D, Shi P, Post W, Olson J, Watson KE, Folsom AR, Lima JA. Heart failure risk prediction in the Multi-Ethnic Study of Atherosclerosis. Heart Jan;101(1): doi: /heartjnl Epub 2014 Nov 7. McMurray J, Adamopoulos S, Anker SD et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure Eur Heart J, 2012;33: These are ACUTE triggering events, in order of frequency, that can promote a patient to subsequently present with heart failure Decreasing frequency Triggering events: Pneumonia or other respiratory process Ischaemia/acute coronary syndrome Arrhythmias including atrial fibrillation Uncontrolled hypertension Non-adherence to medication Worsening renal function Non-adherence to low salt diet Other (excess alcohol /pregnancy /emotional shock/medications such as NSAIDs or chemotherapy/viral infections/vitamin deficiencies) DIAGNOSIS These are the symptoms and signs of heart failure which can support a diagnosis of Heart Failure Symptoms include: Breathlessness Orthopnoea Paroxysmal nocturnal dyspnoea* Lethargy with exertion Ankle swelling Nocturnal cough Nocturia* Weight gain Occasionally wheezing Palpitations and chest pain may also be present Signs may be seen as: Raised jugular venous pressure* Pedal oedema Occasionally ascites Pulmonary crepitations Hapatic pulsation* Third heart sound or gallop rhythm* Apical displacement or valve murmurs such as pan-systolic murmur* * Particularly typical or specific for heart failure

3 PROGNOSTIC FACTORS Frailty assessment Essential to also have a frailty assessment from the physician that is likely to have known the patient the longest, in order to guide whether comorbidities and quality of life are likely to benefit from hospital admission targeted at salvaging heart failure, or whether end of life care is appropriate There are tools for determining prognosis of heart failure patients shown that may help discussion When initially meeting a patient with suspected heart failure, these are the key predictors of poor prognosis (death during hospital admission): Increasing age Echocardiogram LV EF < 35% Concomitant diagnosis of COPD, depression or use of relevant cancer drugs such as anthracyclines Short of breath at rest or with minimal activity (NYHA III/IV)Low initial systolic blood pressure High initial heart rate Lack of cardiology specialist input Pulmonary hypertension Ventricular arrhythmias LBBB on ECG (esp. severe if QRS duration >140 ms) Atrial fibrillation on ECG (esp. fast) Very high admission natriuretic peptide levels Low sodium (below 135) Raised troponin levels Renal function impairment especially egfr < 30 Recurrent unplanned readmission Red flag signs needing emergency admission with suspected heart failure Current or recent chest pain suggestive of acute coronary syndrome Acutely low blood pressure (systolic <85 mmhg) Recent low oxygen saturation (<90%) Ventricular tachycardia or rapid AF Bradycardia with symptoms of dizziness or collapse New valve disease pan-systolic murmur of mitral valve regurgitation Widespread pulmonary oedema to lung mid zones

4 TESTS Initial tests for suspected heart failure in primary care after history and examination O2 saturations ECG and chest X-ray (if both normal low risk of heart failure) Document ECG rhythm especially if AF/LBBB present or not, durations of QRS (esp if >140 ms) and QTc interval (esp. if > 450 ms) FBC, renal profile, liver profile, iron studies, thyroid function NT-proBNP or BNP assay (if natriuretic peptide normal, you have around 98% assurance of having ruled out heart failure): (Assays not needed if prior history of MI go to echo) 1. High levels BNP >400pg/ml (116pmol/l) or NT-proBNP >2000pg/ml (236pmol/l) 2. Raised levels BNP pg/ml (29-116pmol/l) or NT-proBNP pg/ml (47-236pmol/l) 3. Normal levels BNP <100pg/ml (29pmol/l) or NT-proBNP <400pg/ml (47pmol/l) Echocardiogram if BNP abnormal to determine type of heart failure and causes Specifying heart failure type after echo undertaken: HF-REF (all three required) Symptoms typical of heart failure Signs typical of heart failure Reduced LVEF (<50%) HF-PEF (all four required) Symptoms typical of heart failure Signs typical of heart failure Normal or only mildly reduced LVEF and LV not dilated Relevant structural heart disease (LV hypertrophy/left atrial enlargement) or diastolic dysfunction MANAGEMENT Care of patients with established diagnosis should follow the NICE guidance which recommends patients must be given: a confirmed diagnosis of heart failure appropriate knowledge and guidance a personal care plan appropriate input from specialists and counsellors have end of life care planning discussions early be prescribed symptom relief therapies such as diuretics, nitrates, oxygen, hypnotics, flu vaccines be prescribed evidenced based medicines such as ACEi / ARBs, betablockers, aldosterone antagonists, iron replacement, hydralazine+nitrates and coronary disease therapies as needed have underlying causes treated and considered for coronary interventions, valve interventions and pacing interventions as appropriate be considered for an ICD as appropriate be considered for exercise and rehabilitation programmes be regularly reviewed by personnel with appropriate expertise in heart failure to optimise treatments and improve quality and quantity of life and reduce unplanned hospital admissions.

5 Starting and target doses of therapies as per ESC guidelines 1 Starting dose (mg) Target dose (mg) ACE inhibitors Enalapril 2.5 bd bd Lisinopril od od Ramipril 2.5 od 5 bd ARBs to be considered if an ACEi not tolerated Candesartan 4-8 od 32 od Losartan 50 od 150 od Valsartan 40 bd 160 bd Beta-blocker (cardio-selective) Bisoprolol 1.25 od 10 od Carvedilol bd bd Nebivolol 1.25 od 10 od Aldosterone receptor antagonist Spironolactone 25 od od Eplerenone 25 od 50 od Additional drugs under specialist consideration for heart failure patients Clinical Trials Comment Ivabradine SHIFT Recent data from SIGNIFY trial has thrown debate on the value in coronary artery disease therefore watch and wait. Dronedarone ANDROMEDA No longer for patients with LVEF<40% as adverse reactions seen so mainly for AF rate or rhythm control. Needs careful monitoring. Amiodarone EMIAT & CAMIAT An alternative or adjunct to device therapy to prevent atrial and ventricular arrhythmias as appropriate Needs careful monitoring. Iron supplementation e.g. iv ferric carboxymaltose FAIR-HF, CONFIRM-HF Considered for HF patients with ferritin level <100 μg per L or between 100 and 299 μg per L, if the transferrin saturation is <20% Digoxin DIG Needs dose monitoring but useful even in sinus Hydralazine/nitrates V-HeFT I and II Reduce mortality and morbidity for African- Americans with symptomatic heart failure NOT YET LICENCED: Seralaxin RELAX-AHF Valsartan but agent prevents BNP degradation LCZ696 PARADIGM Novel combination with valsartan to enhance BNP persistence in body Finerenone ARTS-HF Non-steroidal aldosterone receptor antagonists not prone to hyperkalemia Omecamtiv ATOMIC-AHF Direct activator of cardiac myosin. Neucardin Phase II RCT rhnrg-1) in chronic heart failure Peptide based therapy (Neuregulin-1)

6 Diagnostics Therapy Monitoring / transition management MINIMUM AUDIT STANDARDS OF CARE Minimum standards. Adapted from NICE guidelines [CG108] Published date: August Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care Standard Adapted from NICE guidelines Comment /interpretation 1 Suspect HF + past MI refer urgently to specialist Urgent specialist referral <two weeks 2 Suspect HF and no past MI - offer NP assay Offer NT-pro/BNP 3 Suspect HF with very high NP assay result Seen in two weeks by specialist 4 Suspect HF with intermediate NP assay result Seen in six weeks by specialist 5 HF - personal info/education/plan Personal management plan 6 HF Multidisciplinary team care with single point of contact MDT clinic 7 Start ACE inhibitors or ARB (A) /Beta-blockers (B)/aldosterone receptor antagonists (A) and optimise doses (bumetanide (B) or furosemide diuretics also needed) ABBA regime 8 Stable HF - promote exercise, rehab, mobility Rehab and step counts 9 Review six monthly with HF treatments and renal function Review and renal bloods every six months minimum 10 HF admission personal plan to be explained Personal care plan 11 HF admission - ensure HF team involved at hospital Input HF specialist team pre-discharge 12 HF discharge only when stable and HF MDT follow-up Post-diagnostic twoweek heart failure MDT clinic 13 Offer patient and carer - HF and end of life discussions Early palliative team access if appropriate