Post on 24-Jun-2020
transcript
Your healthcare closer to home
Heart Failure Management
Aims of this session � To introduce you to our service
� To give an overview of heart failure and specific management of Heart Failure with reduced ejec>on frac>on (HFrEF)
� To discuss case studies
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What is Heart Failure?
� Heart failure is a syndrome consis>ng of typical symptoms and signs (breathlessness, fa>gue and oedema) arising as a result of cardiac dysfunc>on.
� Heart failure is a long-‐term condi>on that oIen gets worse over >me. It can’t be cured, but with treatment and lifestyle changes, many people can have a good quality of life.
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Barnet Heart Func>on Improvement Service
� Team of 4 heart failure specialist nurses – Mandy Thornberry, Jana Roberts, Carolyn Mohamed and Jackie Loughlin
� Clinical lead: Dr Ameet Bakhai, Consultant Cardiologist. � Pa>ents are seen in both at home and in clinics � Our role is to: i. Ensure pa>ents are op>mised on maximum tolerated doses of medicine
to treat heart failure with reduced ejec>on frac>on, LVEF<45% ii. To manage acute exacerba>ons with aim of preven>ng hospital
admissions. iii. Educate pa>ents to self manage their condi>on and be able to recognise
signs of decompensa>on and know when to seek clinical review. iv. Liaise with secondary care for further diagnos>c tes>ng, device
considera>on or complex management. v. Refer to appropriate clinical trials (e.g. Ironman, Emperor ) vi. End of life support
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Prevalence of Heart Failure Na>onally and Locally � BHF Cardiovascular disease sta>s>cs 2018 state that around 550,00 people in the UK are recorded as having heart failure (HF)
� NICE state that the true number (those unrecorded/undiagnosed HF) is likely to be much higher and es>mated to be 920,000 in the UK
� Locally Barnet CCG data from 2017 shows that 2,060 pa>ents were registered as ‘Diagnosed with LVSD Heart Failure’
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Prevalence of Heart Failure � It is es>mated that the prevalence of HF is around 1-‐2% of the adult popula>on and this increases to over 10% in people aged over 70 years.
� Males are affected slightly more than females. � Data from the 2016-‐17 Na>onal Heart Failure Audit highlights that prognosis remains poor; mortality in pa>ents admined with HF is 9.4% during hospital admission with a third of those discharged dying within the following year.
� Following admission to hospital for HF, survival rates are similar to those of colon cancer, and worse than those of breast or prostate cancer.
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What are the symptoms of heart failure?
� Fluid reten>on – swelling of the ankles and or legs and the abdomen
� Extreme >redness � Breathlessness – especially when lying flat � A persistent cough � Lack of appe>te � Weight loss/gain � High heart rate
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Swelling in the feet, ankles, legs or abdomen
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Diagnos>c Tests � BNP or NT-‐proBNP � Echocardiogram: LVEF <45% � Blood tests: ini>al assessment should include FBC, U&Es, TSH, glucose, fas>ng lipid profile and LFT
� A 12-‐lead ECG on all pa>ents presen>ng with heart failure.
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What are the causes of Heart Failure?
1. Coronary Heart Disease-‐ MI 2. High blood pressure 3. Heart muscle weakness (Cardiomyopathy) 4. Heart rhythm disturbance-‐ Atrial Fibrilla>on 5. Heart valve disease, damage or problems with the heart
valves 6. Others: thyroid disease, pulmonary hypertension (high
pressure in the lungs), severe anaemia, viral infec>on affec>ng the heart muscle, alcohol or recrea>onal drugs, some types of chemotherapy and congenital heart problems.
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What are the risk factors in Heart Failure?
1. Smoking-‐ damages the lining of the arteries and increases the risk of blood clot.
2. High blood pressure-‐ heart muscles thicken over>me to cope with the extra workload un>l it becomes either too s>ff or too weak.
3. High cholesterol level-‐ high levels of cholesterol can cause narrowing of the arteries.
4. Diabetes-‐ high levels of glucose can affect the walls of the arteries and increases fany deposits.
5. Overweight 6. Increase alcohol consumpNon-‐ heavy drinking damages the heart
muscles.
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Managing Heart Failure 1. Treat underlying causes of heart failure.
(abnormal heart rhythms, severe anaemia, thyroid problem or ischaemic heart disease)
2. Lifestyle changes 3. Medica>ons 4. Surgery-‐ use of device (pacemaker or CRT),
bypass graI, heart transplant or valve repair
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Medical Treatment for HFrEF � Diure>cs � ACE Inhibitors or ARB in pa>ents intolerant of ACE Inhibitors
� Evidence-‐based beta blockers � Aldosterone receptor antagonist � Entresto – Sacubitril/Valsartan � Ivabradine � Hydralazine -‐ Nitrate combina>on � Digoxin
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Non-‐pharmacological Interven>ons � Educa>on and support to facilitate self care � Symptoms monitoring � Manage comorbidi>es � Regular physical ac>vity � Cardiac-‐Pulmonary Rehabilita>on to improve func>onal capacity, quality of life and mortality
� Sodium restric>on to reduce conges>ve symptoms
� Fluid restric>on in fluid overload 16
Device based treatment and surgical interven>on � ICD � CRT-‐P/ CRT-‐D � Surgical interven>on for IHD – CABG, valve surgery
� Heart transplanta>on
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Case study 1 � Presenta>on: 81 year old female pa>ent presen>ng with increasing shortness of breath
and swollen ankles. � PMx: HTN, Type 2 DM, AF, OA, ECHO from 2017: LVEF 30-‐35%, mild -‐mod MR. � Medica>on: Furosemide 40 mg od, Bisoprolol 2.5 mg od, Ramipril 10 mg od, Merormin,
Warfarin. � SH: re>red teacher, lives alone, independent with ADL, never smoked, rare alcohol
intake, previously able to walk to local shops. � O/E: BP 135/71, radial pulse 88 bpm irregular, SpO2 96%, weight 80 kg (usual weight 76
kg), JVP raised >4 cm, bi-‐basal creps, bilateral leg oedema to mid shin. � Management: � U&E, FBC, CRP, TSH and NT-‐proBNP � Up >trate Furosemide to fluid offload � Repeat ECHO – reassess LV func>on + check on progression of valvular disease � 24 hr ECG, up-‐>trate Bisoprolol and/or consider Digoxin to rate control � Add Spironolactone 25mg od with renal monitoring � Entresto � Devices considera>on � Emperor study � Cardio-‐pulmonary exercise and Educa>onal programme 18
Case study 2 � Presenta>on: 75 yrs male presen>ng with increased breathlessness, no fluid reten>on � PMH:: IHD-‐ MI 2010, primary preven>on ICD 2012, LVEF 40% 2014, COPD, ex-‐smoker,
HTN � Medica>on: Ramipril 10mg, Bisoprolol 7.5mg od, Eplerenone 25mg, Atorvasta>n 40mg
od, Allopurinol 100mg od, Sere>de inh, Salbutamol inh. � SH: lives with wife, part-‐>me working in his business, no alcohol intake, gave up smoking
10 yrs ago (50 pack Hx) � O/E: BP 110/65, HR 58 bpm regular, SpO2 95%, JVP not raised, weight 75 kg (usual
weight), no added sounds on lung ausculta>on, no leg/sacral oedema. � Management: � Bloods � ECG: TVI anterior leads, QRS 156 ms � Repeat ECHO to re-‐assess LV func>on � To consider upgrade to CRT-‐D if LVEF <35% � Respiratory opinion � Liaison with pa>ent’s cardiologist regarding possible worsening IHD +/-‐ Angio
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Summary of management of Heart Failure in a community
1. Relieve symptoms and improve quality of life
2. Slow disease progression 3. Reduce hospital admission 4. Help people live longer
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References � NICE: Chronic heart failure in adults: diagnosis and
management, NG106 September 2007 � Bri>sh Heart Founda>on. Facts and Figures.
hnps://www.bhs.uk/for-‐professional/press-‐centre/facts-‐and-‐figures
� Na>onal Cardiac Audit Programme 2017. Na>onal Heart Failure Audit 2016/17 Summary Report
hnps://www.nicor.org.uk/wp-‐content/uploads/2018/11/Heart-‐Failure-‐Summary-‐Report-‐2016-‐17.pdf
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Ques>ons?
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