Cardiology. Presented by: Dr Paul Bethell GP Lead for Planned Care

Transcription

1 Cardiology Presented by: Dr Paul Bethell GP Lead for Planned Care 16 th April 2015

2 Integrated Cardiology Service for Ipswich and East Suffolk CCG IHT 6 consultants - all with specialist areas PCI CoW rapid access for advice Cardiology Clinical Network continue to monitor and improve system Integrated Community Cardiology Service Consultant led GP Nurse (seeing 20% of current outpatients) Triage of referrals 10% advice only needed Timely and local access max 6 week from referral Letter and management plan within 5 working days Primary Care Education Programme Local Cardiology Pathways (Atrial Fibrillation, Palpitations, Syncope, Heart Failure, Murmurs, Chest Pain/Stable Angina) Pre-Referral Guidelines to avoid delay and duplication Access to diagnostics Echo, BNP, 24 hour ECG, Rapid ECG Analysis, ABPM Telephone Advice (COW) Map of Medicine with standard info leaflets and links to useful websites Self Care and Prevention Patient Involvement Condition Leaflets Website Information Support Groups (Heartbeat)

3 Ipswich Hospital & Ipswich & East Suffolk CCG Previous Diagnosis of Heart Failure in Primary Care Final (V6.0 April 2015) If clinically unwell admit to Ipswich hospital Worsening symptoms & signs suggestive of heart failure This pathway differs from NICE guidelines but local adaptions have been agreed. Low NT-pro BNP (<400pg/ ml) Request NT-proBNP +FBC, U&Es, LFT s, TFT s glucose, INR, ECG, CXR Very elevated NT -pro BNP (>2000pg/ml) Assess for other causes of Breathlessness Normal echo (Discuss with cardiology if heart failure strongly suspected) Intermediate NT-pro BNP ( pg/ ml) Echo if not done within last 12 months & repeat echo if new onset of; Ischaemia (post MI) AF/ other arrhythmia Murmurs/ suspected valvular disease Previously good LV function Abnormal echo Review medications - Increase diuretics and start /increase Ace/ARB (unless contraindicated) If known to Ipswich hospital or Community Heart Failure team contact them to discuss / review. If unknown to either Ipswich hospital or Community Heart Failure team refer for advice or appt Max 2 week wait GP to assess severity Primary care conservative/medical management (Discuss with Ipswich Hospital Heart Failure clinic if needed) Mild LVSD on Echo No severe valve disease Known cause of HF GP confident Optimisation of medical management Palliative care / house bound Known aetiology HF with preserved LV function diagnosed by cardiology Refer to Community Heart Failure team Moderate/Severe LVSD on Echo Significant Valve disease Heart failure not palliative HF with preserved EF on echo Heart failure not responding to NICE guidelines Ongoing cardiology investigations Aetiology of heart failure unknown Device management Significant valve disease Refer to Ipswich Hospital Heart Failure clinic 6 weeks

4 Ipswich Hospital & Ipswich & East Suffolk CCG New Diagnosis of Heart Failure in Primary Care Final (V6.0 April 2015) If clinically unwell admit to Acute hospital admission Signs and symptoms suggestive of heart failure. This pathway differs from NICE guidelines but local adaptions have been agreed. Low NT-pro BNP (<400pg/ ml) Request NT-proBNP +FBC, U&Es, LFT s, TFT s glucose, INR, ECG, CXR Very elevated NT -pro BNP (>2000pg/ml) Assess for other causes of Breathlessness Normal echo (Discuss with Cardiology if Heart Failure strongly suspected) Intermediate NT-pro BNP ( pg/ ml) Start treatment Initiate loop diuretic Refer for Community Echo Abnormal echo GP to manage while awaiting BNP result initiate loop & ACE + ARB unless contra indicated Refer to Hospital Heart Failure clinic Max 2 week wait GP to assess severity Mild LVSD on Echo Clear underlying cause of HF GP confident Moderate/Severe LVSD on Echo Significant Valve Disease Primary care conservative/medical management (Discuss with Hospital Heart Failure clinic if required) Optimisation of medical management Frailty issues (mobility/housebound/palliative) Refer to Community heart failure team Heart failure not palliative HF with preserved EF on echo Aetiology of heart failure unknown Device management Significant valve disease Refer to Hospital Heart Failure clinic 6 weeks

5 The role of NT-proBNP in Heart Failure Sanjay Jeyaseelan MD MRCP Consultant Cardiologist Ipswich Hospital

6 Background Physiology Uses of NT-proBNP Case discussions Conclusions Questions Presentation

7 Heart Failure Common condition with high morbidity and mortality. Leads to hospital admissions and readmissions Can be difficult to diagnose Evidence based treatment available for heart failure which help improves symptoms, prognosis and reduces hospital admissions

8 Symptoms and Signs of Heart Failure Typical symptoms: Dyspnoea, Fatigue, Oedema Typical signs: Raised JVP, Displaced Apex Beat, Gallop Rhythm, Crepitations, Effusions, Hepatomegaly, Ascites, and Oedema

9 NICE Chronic Heart Failure Guidelines Chronic heart failure: management of chronic heart failure in adults in primary and secondary care Clinical guidelines, CG108 - Issued: August

10 Key steps for better HF outcomes Early and accurate diagnosis Mechanism of heart failure Prompt and appropriate treatment Optimising treatment Monitoring

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12 NICE HF cost savings per 100, 000 patients using BNP

13 Heart Failure costs In 2002, 716 million (1.8% of total NHS budget) Hospital in-patient stay 250 per day Echocardiography 60 Cardiology out-patient 160 NT-proBNP 20

14 Heart Failure Pyramid

15 HF treatment available for East Suffolk Advice & Support: Heart Failure & Rehab team Medication: Diuretics, ACE inhibitors, ARBs, B-blockers, Aldosterone antagonists, Digoxin, Ivabradine, Hydralazine, Nitrates Devices: ICD, CRT-P, CRT-D

16 HF treatment available for East Suffolk Cardiac Intervention and Surgery: PCI, CABG, Valvular Surgery Advanced Heart Failure: Inotropes, Haemofiltration, LVAD, Artificial Heart, Transplant End stage Heart Failure: Palliative care

17 The heart as an endocrine organ An endocrine organ secrete hormones directly into the circulatory system to be carried towards a distant target organ Natriuretic Peptides released by the heart Causes vasodilatation, diuresis and sodium excretion Pro Atrial Natriuretic Peptide Pro Brain Natriuretic Peptide

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19 BNP and NT-proBNP

20 Brain Natriuretic Peptide Released by the ventricular myocardium in response to increased intracardiac volume and/or pressure BNP secretion controlled at the transcription level so sustained stimulus is required Causes include LVSD, volume overload, LVH, and ischaemia BNP levels increase with age and renal failure

21 Brain Natriuretic Peptide BNP levels higher than normal in patients with HF BNP levels decrease with diuretics and ACE Inhibitors. BNP levels initially increase with B-Blockers and then decrease. BNP levels decrease with spironolactone and ARBs

22 Diagnosing HF with BNP In one study a NT probnp of 300pg/ml: Sensitivity 94% Specificity 61% Positive Predictive Value 44% Negative Predictive Value 97% Therefore an excellent rule out test Improves diagnostic accuracy

23 HF prognosis and monitoring with BNP Higher the BNP levels the worse the prognosis. Helps identifies patients at most concern. BNP levels fall as HF treated. Levels can be rechecked for exacerbations of HF.

24 History: HF Clinical Evaluation To formulate diagnosis and to monitor response to treatment Age, Gender, Ethnicity, Symptoms (inc. Duration and Severity), PMH of IHD or HTN, Respiratory Disease, Medication, Allergies, Smoker? Alcohol?, Family history of IHD or Cardiomyopathy

25 Aetiology of Heart Failure Heart Failure can occur due to many different causes. Identification of the cause guides treatment.

26 Causes of Heart Failure Ischaemic heart disease (most common cause) Hypertensive heart disease Cardiomyopathy (Dilated, Hypertrophic, Restrictive, Peripartum) Valvular heart disease Congenital Heart Disease Arrhythmia

27 Causes of Heart Failure Viral and other infection (Chagas disease) Alcohol and Drugs Chronic lung disease (Cor Pulmonale/Pulmonary Hypertension) Pericardial Disease Hyperdynamic Circulation disease (Anaemia, Thyrotoxicosis, AV malformations) Connective Tissue Disease

28 Medical Treatment of LVSD HF Loop Diuretics: Improve symptoms Frusemide and Bumetanide ACE inhibitors: Improves symptoms and prognosis. Maximise dose Ramipril, Perindopril, Lisinopril ARBs: Improves symptoms and prognosis. Maximise dose. Candesartan, Losartan, Valsartan B-Blockers: Improves symptoms and prognosis. Maximise dose. Bisoprolol, Carvedilol, Nebivolol, and Metoprolol CR/XL

29 Medical Treatment of LVSD HF Spironolactone and Eplerenone: Improves symptoms and prognosis. Hydralazine and Nitrate: Improves symptoms and prognosis. Up-titrate dose. In place of ACE inhibitors/arbs in Renal Failure Ivabradine: Reduces Hospitalisation. In Sinus rhythm >70/min and B-blocker intolerant/insufficient. Digoxin: Reduces Hospitalisation. In Sinus rhythm or AF and B-blocker intolerant/insufficient.

30 Classification of HF symptom severity New York Heart Association(Little, Brown & Co; 1994) Class 1: previous symptoms now no limitation with ordinary activity, Class 2: slight limitation with activity, Class 3: marked limitation with activity, Class 4: symptoms at rest or unable to carry out any activity without symptoms.

31 Treatment of LVSD HF in NYHA Class 1 Beta blockers (Metoprolol, Carvedilol, Bisoprolol, Nebivolol), ACE inhibitors, and Angiotensin receptor blockers (Candesartan, Losartan, and Valsartan). Maximise beta blocker and ACE inhibitor to highest tolerated dose.(heart rate >55, Blood pressure >90mmHg systolic)

32 Treatment of LVSD HF in NYHA Class 2 Loop Diuretics, Beta blockers, ACE inhibitors, ARBs, Eplerenone (EF<30%), Digoxin Ivabradine (EF<35%, HR>70, sinus), ICD (EF<35%), CRT-D (EF<35% & QRS>120ms),

33 Treatment of LVSD HF in NYHA Class 3 Loop Diuretics, Beta blockers, ACE inhibitors, ARBs, Spironolactone (EF<35%), Digoxin, Metolazone, Hydralazine and Nitrate, ICD (EF<35%), CRT-D (EF<35% & QRS>120ms),

34 Treatment of LVSD HF in NYHA Class 4 Loop Diuretics, Beta blockers, ACE inhibitors, ARBs, Spironolactone (EF<35%), Digoxin, Metolazone, Hydralazine and Nitrate (EF<35%), CRT-P (EF<35% & QRS>120ms), (Inotropes, LVAD, Artificial Heart, Heart Transplant) Palliative Care

35 Heart Failure Pyramid

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38 Case Discussion 1 70 y.o. Male. Previous MI. Type 2 DM (Diet). SOB on 100 yards last 2 months Rx: Aspirin & Simvastatin Pulse 76, BP 140/70, HS: Normal Chest: Bilat. Creps. JVP: Elevated, Oedema of Ankles Plan?

39 Case Discussion 2 25 y.o. Male. Normally fit & well Flu illness 1 month ago Progressive SOB & now at rest too No medication Pulse 120, BP 85 systolic, HS: Gallop, Chest: Dull bases, JVP: Elevated, Legs: no oedema Plan?

40 Case Discussion 3 80 y.o. Female. Known HF. HTN. CKD 2 SOB on exertion for 1 year, now breathless on little exertion. Rx: Frusemide 40mg & Ramipril 2.5mg Pulse 80, BP 150/70, HS: Normal, Chest: Dull bases, JVP: difficult, Legs: Oedema up to knees Plan?

41 Case Discussion 4 68 y.o. Male. Bronchiectasis & HTN SOB for 2 years. SOB worse last week. Has cough Rx: Inhalers, Carbocisteine and Amlodipine Pulse 100, BP 130/80, HS normal, Chest: Bilateral Creps and Wheeze, Legs: mild oedema Plan?

42 Case Discussion 5 54 y.o Male. COPD. Alcohol 40u/week SOB and Palpitations for 2 months Rx: Inhalers prn Pulse 120 irregular, BP 140/80, HS normal, Chest: Basal Crepitations, JVP raised, Legs: ankle oedema NT-proBNP 1500 Plan?

43 Case Discussion 6 70 y.o Female. Overweight but otherwise well Increasing Breathlessness over 6 weeks. Pulse 100, BP 120/70, HS: normal, Chest: Clear, JVP: elevated, Legs: no oedema NT-proBNP 1500 Plan?

44 Case Discussion 7 36 y.o African origin Female. Asthma. FH of DCM. 6 months Post Partum. Breast feeding. SOB despite using inhalers regularly Pulse 100, BP 100 systolic, HS: normal, Chest: Bilateral Crepitations, JVP: difficult, Legs: no oedema NT-proBNP 1800 Plan?

45 Case Discussion 8 69 y.o Female. Hypothyroid. New to practice SOB and tiredness 6 months Rx: Thyroxine Pulse 100, BP 110/70, HS: ESM, Chest: Crepitations in bases, Legs: no oedema NT-proBNP 2500 Echo: Moderate LVSD, Suggestion of Severe AS Plan?

46 Case Discussion 9 85 y.o Male. Lives in RH, mobilises with Frame, HTN, Type 2 DM, CKD 3, SOB and oedema Rx: Bendrofluazide & Metformin Pulse 80, BP 160/90, HS normal, JVP raised, Chest: Dull bases, Legs oedematous NT-proBNP: 1900 Echo: Normal LV systolic function, Mild AS, Mild MR Plan?

47 Case Discussion y.o. Male Previous CABG, Known HF, new to Practice. Had problems with gynaecomastia in the past SOB on exertion but plays Golf Rx: Frusemide 40mg, Ramipril 5mg, Bisoprolol 1.25mg Pulse 76, BP 96/50, HS normal, Chest clear, JVP normal, Legs, no oedema NT-proBNP 600 ECG SR 75/min LBBB, normal PR Echo: Severe LVSD, Mild MR Plan?

48 Conclusions Identify Heart Failure patients early Establish cause of HF Educate patient Start treatment as soon as possible Maximise treatment Monitor patients

49 Questions?