Charles Spencer MD, FRCP Consultant Cardiologist Mid Staffs NHSFT

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1 Charles Spencer MD, FRCP Consultant Cardiologist Mid Staffs NHSFT

2 Key Messages Heart Failure is Common Heart failure is complex Heart Failure is a major issue for the NHS Heart Failure has a worse prognosis than some common cancers You have a 1 in 5 chance of getting Heart Failure

3 Definition HF is a syndrome in which the patients should have the following features: symptoms of HF, typically shortness of breath at rest or during exertion, and/or fatigue; signs of fluid retention such as pulmonary congestion or ankle swelling; and objective evidence of an abnormality of the structure or function of the heart at rest. (ESC 2008)

4 How does Heart Failure Present? Clinical Feature Symptoms Signs Peripheral oedema/congestion Pulmonary oedema Cardiogenic shock High blood pressure (hypertensive heart failure) Right heart failure Breathlessness Tiredness, fatigue Anorexia Severe breathlessness at rest Confusion Weakness Cold periphery Breathlessness Breathlessness Fatigue Peripheral oedema, Raised JVP Pulmonary oedema Hepatomegaly, ascites Fluid overload, Cachexia Crackles or rales over lungs, effusion Tachycardia, tachypnoea Poor peripheral perfusion SBP,90 mmhg Anuria or oliguria Usually raised BP, LV hypertrophy, and preserved EF Evidence of RV dysfunction Raised JVP, peripheral oedema, hepatomegaly, gut congestion

5 Causes of Heart Failure Coronary artery disease 70% Valve disease 10% Cardiomyopathies 10% Hypertension Toxins e.g. Alcohol, cocaine Drugs e.g. cytotoxics Metabolic e.g. Diabetes, Cushings, acromegally Infiltrative e.g. amyloid, sarcoid

6 Systolic vs. Diastolic Systolic Impaired contractility Reduced ejection fraction Younger patients Dilated cardiomyopathy Ischaemic Heart Disease Large evidence base for treatment Worse prognosis Diastolic Impaired cardiac filling Normal ejection fraction Older patients esp. women Hypertension, diabetes Restrictive and hypertrophic cardiomyopathy Limited evidence for treatment Probably better prognosis

7 Undiagnosed Heart Failure Only 50 percent of patients with left ventricular dysfunction are symptomatic Asymptomatic structural or functional abnormalities of the heart are associated with a high mortality

8 Epidemiology 15 Million patients in Europe have Heart Failure, 900,000 in UK 4% of the population have HF or asymptomatic LVSD Prevalence in over 75s 10 20% Mean age of HF patient is 75 Lifetime likelihood of developing HF is approximately 20 percent at all ages above 40

9 Epidemiology Prevalence is increasing Ageing population Better acute treatment for Acute Coronary Syndromes Better secondary prevention after ACS Better survival with improved heart failure treatment

10 Burden of Symptoms Physical Breathlessness Oedema Fatigue Cachexia Psychological Depression, anxiety Social Isolation, financial

11 Economic Burden 2% total NHS budget spent on HF 70% cost attributable to secondary care 45 million on GP consultations 129 million on drugs in primary care Cost to patient Prescriptions Loss of income

12 Burden on secondary Care Primary cause of 5% of hospital admissions HF is present in 10% of hospital in patients 1 in 4 re admitted within 3 months Accounts for 2% of health service costs Most of cost is due to hospital admissions

13 Prognosis 30 40% of patients die within 1 year of diagnosis 10% per year mortality thereafter 5 year survival if on GP HF register 58% compared to 93% if not Survival worse than Breast Cancer 10,000 deaths directly due to HF / year in UK ~100,000 major cause

14 Progression and Mode of Death Variable and fluctuant course Approximately 1/3 sudden death im apparently stable patient. 1/3 Sudden death on background of worsening pump failure 1/3 progressive pump failure

15 Some Good News 6 month mortality % 6 month mortality %

16 Reasons for improvement Better access to diagnosis More use of evidence based treatments ACE inhibitors Beta blockers Spironolactone/eplerenone Devices Better access to specialists In patient mortality under generalist 12% In patient mortality under Cardiologist 6%

17 Conclusion Heart Failure is increasing in prevalence Survival is slowly improving Prognosis remains worse than some common cancers Specialist care makes a difference Good palliative care makes a difference

18 Any Questions?