Heart Failure A Marvellous Story with More to Come Prof Ken McDonald National Clinical Lead for Heart Failure
Advances in Heart Failure over Last 20 years Pharmacotherapy in HF-REF ADHF 50-15% Community 5 yr : 55% One mth /yr Device Rx in HF-REF Heart Failure Disease Management Programmes
Emerging new Strategies for Health Care in the Future Heart Failure Could the Cinderella of Medicine be the Guiding Light for Future Care
Emerging New Strategies for Heart Failure in the Future HF-PEF Prevention Heart Failure Primary-Secondary Care Interaction
Emerging New Strategies for Heart Failure in the Future HF-PEF Prevention Heart Failure Primary-Secondary Care Interaction
Heart Failure Numbers Now 20% Total At-Risk Population 1,000,000 Ireland 150,000,000 Europe 2030 Risk factor Control Diabetic Epidemic Lifestyle Improved Survival Prevalence to Increase by ~50%
The STOP-HF Story The First Personalised Approach to the Prevention of Heart Failure
At Risk Population ~1Million ~150 million Superior Risk Definition and Focused Use of Resources Critical to CV Management
Superiority of Natriuretic Peptide as Risk Indicator Hypertension, Diabetes, Obesity, Age, Cardiotoxins, etc Risk of Cardiovascular Damage Cardiovascular Damage Release of Natriuretic Peptide indicating Cardiovascular Damage Focus of Prevention Strategy
Natriuretic Peptides personalise Heart Failure Risk Wang et al, NEJM 2004
STOP-HF Hypothesis NP-driven screening and targeted collaborative care in the general at-risk population will decrease the prevalence of LVD and HF 39 collaborating primary care practices, intervention provided in a single referral center STOP-HF, JAMA, 2013
STOP-HF Intervention Routine PCP care NP-directed care In addition to routine PCP care Annual BNP in all Annual BNP not available to clinicians At least annual review by PCP Cardiology review only if requested by PCP If BNP >50pg/ml at any time Shared-care Cardiology review Echo-Doppler Other CV investigations CV nurse coaching Regular Cardiology follow-up STOP-HF, JAMA, 2013
Primary Endpoint HF and LVD OR 0.46 [0.27, 0.77], p=0.003 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% OR 0.59 [0.38, 0.90], p=0.01 N=59 3.8% 2.8% 2.1% N=39 N=44 6.4% N=25 7.2% 3.0% 2.0% 4.6% 2.3% 5.1% 1.0% 1.9% 677 697 235 263 Control Intervention Control Intervention Total All patients Population Any BNP > >= 50 50 pg/ml LVDD LVSD HF STOP-HF, JAMA, 2013
Number of events per 1,000 patient years Endpoint MACE Event Rate 45 Event Rate OR 0.54 p=0.001 vs. Control 40 35 30 25 20 15 10 5 11 3.8 3.8 6.2 15.5 5.5 1.4 2.7 2.7 9.9 Stroke/TIA PE/DVT MI Heart Failure Arrhythmia 0 Control Intervention N=71 (10.5%) N=51 (7.3%)
The PONTIAC Study Achieved Primary End-point: Hospitalisation or Death / Cardiac Effectiveness of RAAS / BB Titration JACC, 2013
STOP-HF and PONTIAC; Comparison of Pharmacotherapy at Study End 100 90 80 Intervention Control 70 60 50 40 30 20 10 0 PONTIAC BB STOP-HF BB PONTIAC RAAS STOP-HF RAAS
Cost Analysis of STOP-HF CONTROL Control (n=522) Mean (SD) INTERVENTION Intervention (n=533) Mean (SD) 6,238 per gain life year free of MACE CV Emergencies 1460 (4478) 795 (3010)** CV Electives 1471 (6702) 1311 (5314) Investigations/Tests 503 (599) 875 (951)** Non-CV Emergencies 1622 (4495) 1684 (4521) Non-CV Electives 2600 (5862) 2552 (5149) Medications 1776 (999) 1902 (1095) STOP Visits - 352 (460)** BNPs 61 (29) 71 (31) GP visits 197 (95) 232 (102)* Total 9689 (12353) 9774 (11049) Intention to treat 7495 (9446) 7614 (8698) The incremental cost per LVD/HF prevented was 2693 (sensitivity -7540 to 12926) and per MACE prevented 1139 (sensitivity -3190 to 5469) Ledwidge et al, Athens 2014
Event rate per 100 patient-years Hospitalisation & Death Across Spectrum 45 40 35 30 25 20 15 10 5 0 42 * 12.4 * 11.1 8.1 7 7.4 * * * * * 1.6 2.9 * 2.1 0 0 0.6 HF event Non-HF CV event Non-CV event Death Stage A Stage B Stage C
Services in Republic of Ireland Dublin South Wicklow Wexford STOP-HF
Services in Republic of Ireland Westmeath Offaly Laois STOP HF Midlands
Emerging New Strategies for Heart Failure in the Future HF-PEF Prevention Heart Failure Primary-Secondary Care Interaction
How Complex if Heart Failure Management? The Diagnostic Challenge The Therapeutic Challenge
Damn Difficult Diagnosis 22-01-2016: Is it or Isn t it 78yrold male - GP referral-rapid access clinic DOE ( Class 11 )-commenced on low dose loop? Marginally better AF for years Previous normal Cors No lung history Exam AF-no volume overload ; BMI 30 ECG : AF nil else NP ( BNP) : 136pg/ml Echo Normal EF, Biatrial Enlargement, normal Valves, no increase in Pulmonary Pressures
How Complex if Heart Failure Management? The Diagnostic Challenge Using Echo properly Not just LVEF / Valve LA for PEF E /e Prime Understanding NP Two assays RCV 30% The Therapeutic Challenge
Confidence if Diagnosing HF-PEF: Cardiologists: 58% General Physicians: 43% General Practitioners: 7% Heart Failure Nurses: 6% 2015
How Complex if Heart Failure Management? The Diagnostic Challenge The Therapeutic Challenge HF-REF: Diuretic Nitrate ACEi / ARB/ AA/ ARNi Ivabradine Digoxin Inodilators Device Rx HF-PEF? Co-morbidity Symptom Differentiation Polypharmacy
Barriers Explaining Practice Gap in Ireland Waiting times for outpatient appointments Lack of access to echocardiography Inadequate access to Natriuretic Peptide testing Patients unable to attend outpatients Unsure of interpretation of tests Other Yes (%) 89.4% (n=222) 81.4% (n=226) 63.4% (n=227) 37.5% (n=224) 34.4 % (n=221) 3.1% (n=228) 68.8% of GPs in urban practices would refer over 50% of their patients for specialist opinion 50.6% of mixed urban-rural practices
Practice Gap in the UK 34% of patients with an existing clinical label of heart failure in general practice records had this diagnosis confirmed following echocardiography Hobbs FDR et al. Reliability of N-terminal pro-brain natriuretic peptide assay in diagnosis of heart failure: cohort study in representative and high risk community populations. BMJ 2002;324:1498 503 Most patients are diagnosed on symptoms and signs alone, with only 32% having further investigations or referral. Hobbs FDR et al. European survey of primary care physician perceptions and practice in heart failure diagnosis and management (Euro-HF study). Eur Heart J 2000;21:1877 87.
Practice Gap in Sweden
Practice Gap The Challenge Prompt diagnostics t Prompt specialist opinion Self care education Process of refreshing care to reflect advances, impact of evolving comorbidities Process of re-enforcing self care
Outpatients ED Admission
Many medical interactions don t require the patient!!! ehealth Keep the limited real slots for needed patient review Outpatients ED Admission
262 cases reviewed by VC May 2014 Oct 2015
82% do not require referral to out-patients
50,000 km saved in travel Elderly/Frail. Multiple comorbidities. Limited means to travel.
Emerging new Strategies for Health Care in the Future Heart Failure Focus on Prevention and Enhanced Communication between Primary and Secondary Care