Inverclyde CHP Protected Learning Event- Heart Failure

Transcription

1 Inverclyde CHP Protected Learning Event- Heart Failure 14:00 14:05 14:05 14:20 14:20 14:30 14:30 15:10 15:10 15:30 15:30 15:50 15:50 16:05 16:05 16:35 Welcome & Introduction Paul Forsyth (HF Pharmacist) Eric Gray (Community HF Nurse) Dr Brian Murphy (Consultant cardiologist) New HF diagnostic pathway, QoF & HF LES (Paul / Eric/Brian) Under-reporting of HF in Qof in NHS GGC (Paul) HF Medication Up-date (Brian) Tea & Coffee Break New Community HF Nurse Role (Eric) New Palliative Care HF Pilot / Clinic (Iain Armstrong /Yvonne Millerick- BHF/Marie Curie Caring Together ) Case Studies

2 HF in Inverclyde: Key Contacts Dr Brian Murphy (Consultant Cardiologist, IRH) Taking a lead in developing heart failure services at IRH Eric Gray (community HF nurse) Linking with new LES pathway / triaging patients / CMPs Patient education programme for new diagnosis Stable NYHA I-II patients able to attend group sessions Practical support / advice to PNs/GPs for LES eric.gray@nhs.net or Sheila Skinner & Lorraine Carey-Gardner (HF liaison nurses from IRH) HF due to LVSD patients after recent hospital admissions Complex NYHA III-IV patients living in community HF clinic at IRH & home visits sheila.skinner@irh.scot.nhs.uk or lorraine.carey-gardner@irh.scot.nhs.uk Paul Forsyth / Chaz Tuhan (HF pharmacists) Direct support to GP practices Medication review audits & clinics Disease register audits Support to community pharmacies paul.forsyth@nhs.net or

3 Heart Failure: New Diagnostic Pathway (Currently in Victoria Inf), Paul Forsyth / Eric Gray QoF & HF LES CH(C)P Protected Learning Events Inverclyde CHCP Sept 2010

4 Currently only at pilot stage but if successful may roll out city wide

5 Diagnostic Pathway Victoria Infirmary May patients in pilot 3 DNA 58% (56) had normal ECG & BNP No echo done & patient returned to GP for other investigations 42% (41) had either abnormal ECG or BNP & echo carried out 7 returned with GP with specific management plan & echo result 1 LVSD 4 normal 2 misc (i.e. LVH with raised BNP) 7 given cardiology appoint 3 LVSD 4 Misc (i.e. valvular) 19 GPs sent result but no changes to meds needed so no recommendations 15 normal 2 LVSD and on correct therapy 2 misc (i.e. LVH and on therapy) 6 deviations from pathway (i.e. inappropriate referral, recent echo done at cardiology etc) 1 onward referral to investigate anaemia as cause of SOB 1 admitted as inpatient (EF10% & pericardial fluid) Average wait for BNP analysis was approx 1hr

6 Current QoF Commitments in HF due to LVSD Indicator Points Thresholds HF 1. The practice can produce a register of patients with heart failure. 4 N/A HF 2. The percentage of patients with a diagnosis of heart failure (diagnosed after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment. HF 3. The percentage of patients with a current diagnosis of heart failure due to left ventricular dysfunction (LVD) who are currently treated with an ACE inhibitor or angiotensin receptor blocker, who can tolerate therapy and for whom there is no contraindication. HF 4. The percentage of patients with a current diagnosis of heart failure due to LVD who are currently treated with an ACE inhibitor or angiotensin receptor blocker, who are additionally treated with a beta-blocker licensed for heart failure, or recorded as intolerant to or having a contraindication to beta-blockers % % %

7 HF LES: likely components at Record aetiology NYHA Class Oedema status PND / orthopnea Pulse BP Height / weight / BMI Medicines ACE (or ARB) Beta-blocker Spironolactone if NYHA III Near patient testing LES for bloods Compliance Patient education annual review New patient education programme (Eric will cover later on) My Heart Book (HF version) Lifestyle advice Vaccinations Depression / HADS Palliative Care Gold Standard Framework Palliative care HF clinics referral (Iain Armstrong will cover later on)

8 Heart Failure: Under-reporting reporting in QoF in GGC Paul Forsyth Heart Failure Pharmacist / CH(C)P Protected Learning Events Summer 2010

9 QoF Analyser- HF Prevalence Estimated prevalence of symptomatic HF in Scotland in 2000 was 85,000 in 5.1m = 1.67% Stewart et al Heart 2003 ECS 2008 European Society Cardiology (ESC) estimate HF prevalence in Europe of 2-3% of general population and approx 4% if you include asymptomatic LVSD GGC prevalences from QoF data Overall HF 2008/2009 =0.87% HF due to LVSD 2008/2009 =0.67%

10 Audit by HF Pharmacists: Last 20 practices Average 19 patients per practice unread-coded but have confirmed HF Last 20 practices

11 Impact of Audit Comparison graphs of practices QoF figures Practices who received pharmacist support during contract year 08/09 (16) vs those who did not (254) (Data Source- official QoF stats supplied by Tom Clackson)

12 Reasons for Patients Not Being Identified Properly by Practices Patients with existing HF due to LVSD diagnosis un-identified due to: Poor transfer of diagnosis from 2o care letter to GP computer systems (i.e. poor admin) QoF doesn t recognise certain diagnosis terms for contract Cardiomyopathy Left Ventricular Systolic Dysfunction Etc Poor / ambiguous info from 2o care Diagnosis hidden with-in content of a letter Echo reports difficult to interpret Lack of time / resource / specialist focus from practice staff Be aware of this & audit register if concerned Search for read-codes not recognised by QoF Search for diuretic / spironolactone users Review post-mi patients histories at annual reviews Signs / symptoms suggestive of HF? Echoed at time of MI

13 Heart Failure (due to LVSD) Medication Paul Forsyth Heart Failure Pharmacist / CH(C)P Protected Learning Events Summer 2010

14 Under-prescribing of key therapeutic treatments Low numbers of patients on key therapies ACE / ARBs 80% Beta-blockers 32% European Journal of Heart Failure. 5(4):549-55, 2003 Aug * Partially carried out in Scotland in 2002 Low number of patients on key target doses 49% of the patients on ACE 18% for Beta-blockers 9% for ARBs European Journal of Heart Failure. 9(12): , 2007 Dec

15 How should we medicate HF (LVSD) patients? All HF (LVSD) patients: ACE (or ARB if not tolerated) Beta-blocker Loop Diuretics (if needed for fluid retention) More symptomatic/complex patients: ARB (along with ACE) Aldosterone Antagonists (Spironolactone( / Eplerenone) Digoxin Combination Diuretics (loop + thiazide)

16 ACE Inhibitors NYHA I - IV Improves survival, improves symptoms & decreases hospitalisations Mortality NNTs- 22 for Mild-mod HF over 40 month, 7 for sev HF over 6 months Contra-indications: History of angioedema / allergy Bilateral renal artery stenosis Cautions / Seek Specialist Advice: Serum K+ > 5.0mmol/L Serum Cr > 220umol/L Significant aortic stenosis- cardiologist should advise on basis of echo result Systolic BP < 90mmHg Drug interactions to be mindful of: Potassium sparing diuretics & potassium supplements low-salt substitutes (generally contain KCl)

17 ACE Inhibitors: How to use them? Start on low dose U&Es before starting Re-check U&Es 1 week after starting Consider titrations after 2 weeks Re-check U&Es 1 week after each titration In the absence of problems aim for evidence-based target doses: ATLAS trial showed 15% relative risk reduction in HF patient with high dose Lisnopril vs low dose Ramipril 10mg OD (or 5mg BD) Enalapril 10-20mg BD Lisinopril 30-35mg OD Captopril 50mg TID Patients on higher doses have better long-term outcomes

18 ACE Inhibitors: Problem Solving Worsening Renal Function Cr <20% or <220umol/L- acceptable Cr >20% or >220umol/L- seek specialist advice & consider reducing/stopping In many cases cardiology will accept Cr rises of up to 50% High Potassium K+ <5.5 mmol/l- acceptable K+ >5.5 mmol/l- seek specialist advice & consider reducing/stopping K+ >6.0 mmol/l- stop immeadiately Persistent Dry Cough Exclude other causes of cough Pulmonary oedema, COPD, asthma, chest infection etc Consider stopping ACE for 1-2 weeks If cough improves start ARB - If it doesn t improve restart ACE In more severe patients seek specialist advice before stopping ACE Symptomatic Hypotension Review need for other BP lowering drugs If no signs of congestion / fluid retention consider reducing diuretic If this doesn t work- seek specialist advice

19 Beta-blockers NYHA I IV (although evidence better for II IV) Improves survival, improves symptoms & decreases hospitalisations Mortality NNTs- 23 for Mild-mod HF over 1 year, 14 for sev HF over 1 year Contra-indications: Asthma Heart block Sinus bradycardia :- Pulse <50 bpm Misconceptions COPD is NOT an absolute contra-indication If reversibility on spirometry is ve then betablockers are OK to trial PVD is NOT an absolute contra-indication Cautions / Seek Specialist Advice: NYHA Class IV (i.e. SOB at rest) Current or recent worsening of HF symptoms <4 weeks Systolic BP < 90mmHg Drug interactions to be mindful of: Rate limiting Ca blockers (i.e. Verapamil / Diltiazem) Digoxin / Amiodarone

20 Beta-blockers: How to use them? Start on lowest dose BP / Pulse / Symptoms before starting BP / Pulse / Symptoms 1-2 weeks after starting Consider titrations after 2 weeks Re-check BP / Pulse / Symptoms 1-2 weeks after each titration In the absence of problems aim for evidence-based target doses: Sub-analysis of CIBIS-II showed that all-cause mortality was significantly reduced in high dose vs low dose Bisoprolol Bisoprolol 10mg OD Carvedilol 25mg BD 50mg BD if patient >85Kg Nebivolol 10mg OD (only use 3 rd line - if not tolerated Bis/Carv) Patients with better heart rate control on a beta-blocker have better long-term outcomes Advise patients to monitor for signs of clinical worsening We can educate patients to report worsening symptoms & increase diuretic dose in short-term if needed

21 Patients on other non-evidence based beta-blockers blockers We should consider switching patient onto evidencebased beta-blockers Atenolol < or = 50mg switch to Bisoprolol 2.5mg Atenolol > 50mg switch to Bisoprolol 5mg Then titrate dose according to BP / pulse / symptoms (as per previous slide)

22 Beta-blockers: Problem Solving Worsening congestion / increased symptoms Increase dose of diuretic and/or consider halving dose of betablocker If serious deterioration- seek specialist advice & consider stopping Bradycardia If pulse < 50bpm & symptomatic half dose of beta-blocker If severe bradycardia- seek specialist advice & consider stopping Review need for other pulse lowering drugs (i.e. digoxin / diltiazem / verapamil etc) Consider arranging ECG to exclude heart block Hypotension As per advice in ACE slide

23 Diuretics Recommended in patients with heart failure & clinical signs of congestion In general a loop diuretic is first line (normally furosemide) Start with a low dose (furosemide 40mg) & increase in increments (of furosemide 40mg) until clinical improvement in signs and symptoms of congestion Can be useful to switch from Furosemide to Bumetanide when higher doses are needed Bumetanide is better absorbed from gut (better bioavailability) Rough equivalence > Furosemide 40mg = Bumetanide 1mg If patient reaches Furosemide 80mgBD or Bumetanide 2mgBD & still has signs of congestion seek specialist advice (HF nurses / cardiology) Loop and thiazide (Metolazone / Bendroflumethiazide) combination can be useful seek specialist advice

24 What next? If patient is still significantly symptomatic after ACE (or ARB), Beta-blocker & diuretic CARDIOLOGY REFERRAL

25 ARBs Patients Intolerant of ACE persistent troublesome dry cough Patients still significantly symptomatic despite being optimised on ACE & beta-blocker (NYHA II-IV) generally only on specialist / cardiologist advice If using in place of ACE follow same advice as per ACE slide If intolerant of ACE & ARB seek specialist advice & consider Hydralazine / ISDN If using ACE + ARB U&Es monitoring Before starting, after 1 week, 2 weeks, 4 weeks, every 4 weeks for 3 months, every 3 months for 1 year then 6 monthly thereafter In the absence of problems aim for evidence-based target doses: Candesartan 32mg OD Valsartan 160mg BD (used post-mi only) Problem solving- as per ACE slide

26 Aldosterone Antagonists Spironolactone NYHA III or IV (already optimised on ACE & beta-blocker) Eplerenone 3-14 days Post MI + LVSD + clinical HF symptoms or diabetes Or patients intolerant of spironolactone due to gynaecomastia Numerous benefits: Improve LV function Improve symptoms Increase survival Decrease hospitalisations

27 Aldosterone Antagonists: How to use them? U&Es monitoring Before starting, after 1 week, 2 weeks, 4 weeks, every 4 weeks for 3 months, every 3 months for 1 year then 6 monthly thereafter Contra-indications: Serum K+ > 5.0mmol/L Already on combination ACE + ARB ACE + ARB + Spiro is not recommended (SIGN 95)- seek advice if you see a patient on all 3 Cautions / Seek Specialist Advice: Serum Cr > 220umol/L Drug interactions to be mindful of: Potassium sparing diuretics & potassium supplements low-salt substitutes ACE / ARB / NSAID Target Dosing: Spironolactone 25mg OD Eplerenone 50mg OD

28 Aldosterone Antagonists: Problem Worsening Renal Function Solving Cr <20% or <220umol/L- acceptable Cr >20% or >220umol/L- seek specialist advice & reduce dose or consider stopping High Potassium K+ <5.5 mmol/l- acceptable K+ >5.5 mmol/l- seek specialist advice & reduce dose or consider stopping K+ >6.0 mmol/l- stop immeadiately Advice to Patient Diarrhoea / Vomitting stop spironolactone & contact doctor Avoid OTC NSAIDs (i.e. Ibuprofen etc) Avoid salt substitutes

29 Digoxin Heart Failure & sinus rhythm NYHA II-IV Already optimised on other conventional evidence-based meds Heart Failure & Atrial Fibrillation Useful for pulse/rate control Beta-blocker preferred if possible May need both agents however Minimal benefit: Decrease hospitalisations Possible symptomatic benefit Problems / Things to consider Troublesome in patients with renal impairment Problems with toxicity Be vigilant of signs- bradycardia,, nausea, vomitting,, anorexia, confusion etc

30 Other Treatments Cardiac Resynchronisation Therapy (CRT) Can reduce symptoms & reduce HF hospitalisations QRS > 120ms NYHA III IV LV ejection fraction < 35% Receiving optimal therapy Implantable Cardiac Defibrillator (ICD) Can reduce mortality in certain high risk patients Primary Prevention NYHA I III Receiving optimal therapy Expected survival > 1 year LV ejection fraction < 35% Secondary prevention Patients who have survived cardiac arrest/ VF or unstable VT Left Ventricular Assist Devices Normally used as a bridge to transplant Cardiac Transplant

31 QUESTIONS? Ivabradine (SHIFT Trial) etc?