8. Pharmacological Management

Transcription

1 8. Pharmacological Management

2 Neurohormonal deactivation 1. Adrenaline Beta Blockers Dose Side Effects Monitoring

3 Neurohormonal Deactivation 2. Angiotensin II ACE Inhibition Dose Side Effects Monitoring

4 ARNI Angiotensin receptor/neprilysn Inhibition

5 ARNI

6 Neurohormonal Deactivation 3. Aldosterone MRA Dose Side Effects Monitoring

7 Symptomatic management Diuretics Loop/thiazide Dose Side Effects Monitoring

8 Other Pharmacological agents and contraindications Digoxin Oral Anticoagulations NOACS Ivabradine Antianginals Antihypertensives Palliative Medications Contraindications

9 9. Non Pharmacological Management

10 Non Pharmacological Management Anxiety/stress management Depression/low mood Support Groups Telehealth Salt intake Fluid intake Dry mouth

11 I would like to introduce.!

12 11. Palliative Care

13 Heart failure has a poor prognosis Heart failure mortality remains unacceptably high % of patients die within the first year of diagnosis(cowie et al, 2000; Hobbs et al, 2007). 1 year survival rates are worse than those for breast, prostate and bladder cancer but better than those for lung and stomach cancer, and very similar to that for cancer of the colon (Stewart et al, 2000).

14 Prognosis for valve disease and heart failure with preserved ejection fraction is the same as that for patients with ejection fraction < 40% -LVSD. Deprivation associated with increased morbidity patients admit to hospital 5 years earlier than those living in more affluent areas.

15 National Heart Failure Audit report from 2009/2010 represents data relating to registered organisations Mortality rate falls from 32% to 23 % for patients who are followed up by a Cardiologist or have access to specialist heart failure services. Inpatient mortality 6.4% for cardiology ward patients and 12.4% for general ward patients

16 Heart failure patients more likely to die in hospital and receive invasive investigations and treatment interventions that may go against their wishes (Lynn et al, 1997). Very few applications for financial support DS1500 (Onac et al, 2010). Absence of emotional support in the older heart failure patient (Froggatt, 2001). Increased incidence of clinically significant depression associated with increases in mortality (Rutledge, 2006).

17 Inequalities Barriers to receiving information and choices in care including Preferred Place of Care and Advanced Care Planning (Levenson et al, 2000; Boyd et al, 2004; NHS Improvement, 2010). Patients are living and dying with significant symptom burden that is sometimes greater than patients dying from cancer (Anderson et al, 2001). Poor quality of life directly linked to symptom burden (Bennett et al, 1998).

18 Heart failure patients more likely to die in hospital and receive invasive investigations and treatment interventions that may go against their wishes (Lynn et al, 1997). Very few applications for financial support DS1500 (Onac et al, 2010). Absence of emotional support in the older heart failure patient (Froggatt, 2001). Increased incidence of clinically significant depression associated with increases in mortality (Rutledge, 2006).

19 Prognostication Advancing age Refractory symptoms despite optimal therapy 3 episodes of decompensation in less than 6 months Dependent with more than 3 ADL s Cachexia (>5% non-fluid related weight loss) Progressive renal dysfunction Resistant hyponatraemia Serum albumin < 25g/l Multiple shocks storms from device Jaarsma et al (2009)

20 Use your clinical acumen and experience ESCAPE trial large multicentre study indicated that nurses predictions of death were more accurate than a prognostic model based on BP, renal function, and exercise tolerance. Yamokoski et al(2007)

21 Symptom Control Physical and psychosocial distress are directly related with heart failure pathophysiology therefore therapies that address the pathophysiology of heart failure and improve cardiac function similtaneously palliate heart failure related symptoms Goodlin (2009)

22 Patients with advanced heart failure often suffer with refractory symptoms including: Breathlessness Persistent cough Pain Fatigue Limitations in physical activities Depression Anxiety Insomnia Cachexia Nausea Constipation

23 Oedema Dyspnoea Cough Pain Nausea & Vomiting Cachexia/anorexia Constipation Symptom Control Diuretics synergistic blockade IV- Abx- Cream Diuretics O2-Nitrates-NaCl nebs-low dose morphine- Lorazepam Diuretics- ACE intolerant- Abx- NaCl nebs- Codeine- low dose morphine Angina/hepatic nitrates colchine/allopurinol gout MS avoid NSAID gel better option- paracetamol Avoid cyclizine -CKD 4 Haloperidolreduced peristalsis -Metoclopramide Refer to dietician MUST score encourage small frequent meals of choice Routine aperients- Senna/Lactulose Idrolax Co-danthramer

24 Symptom Control Depression Refer Talking Therapies Specialist Palliative Care - Avoid tricyclic Choose SSRI- Citalopram, Sertraline, Mirtazepine if nausea Anxiety and poor appetite Refer as above Consider Anxiolytic Lorazepam, Diazepam, Insomnia Fluoxetine, Citalopram Review of symptoms sleep hygiene- Consider -Temazepam- Lorazepam- Zopiclone Fatigue and Lethargy Check Hb, U&E s, TFT refer for aids and adaptations OT- physion

25 Breaking down the barriers- current initiatives: British Heart Foundation commissioned National Council for Palliative Care to research barriers to communication and difficult conversations from a patient/carer perspective Dying Matters Lets talk about it coalition of NCPC aims to change public attitudes and behaviours around dying, death and bereavement.

26 BHF ICD deactivation at the end of life: Principles and practice A discussion document for healthcare professionals

27 10. Device Therapy

28 CRT and ICD NYHA class QRS interval I II III IV <120 milliseconds ICD if there is a high risk of sudden cardiac death ICD and CRT not clinically indicated milliseconds without LBBB ICD ICD ICD CRT-P milliseconds with LBBB ICD CRT-D CRT-P or CRT-D CRT-P 150 milliseconds with or without LBBB CRT-D CRT-D CRT-P or CRT-D CRT-P LBBB, left bundle branch block; NYHA, New York Heart Association

29 6Fwc

30 CRT