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. Definition. Heart failure has been defined as a
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1. An Introduction to Heart failure managementHayley Pryse-Hawkins Heart Failure NurseRoyal Brompton Hospital020 73518744
3. Definition Heart failure has been defined as a ‘syndrome which develops as a consequence of cardiac disease and is recognised clinically by a constellation of symptoms and signs produced by complex circulatory and neurohormonal responses to cardiac dysfunction’.
4. More definitions!
5. ESC definition: Acute Heart Failure The rapid onset of symptoms and signs secondary to abnormal cardiac function….with or without previous cardiac disease
The cardiac dysfunction can be related to systolic or diastolic dysfunction, to abnormalities in cardiac rhythm, or to preload and afterload mismatch.
AHF can present as:
acute de novo, or
acute decompensation of chronic heart failure
6. Symptoms consistent with heart failure:
dyspnoea, fluid retention, effort intolerance
Evidence of fluid retention:
Peripheral oedema and raised JVP, or chest radiograph showing pulmonary oedema or effusions
Clinical evidence (including echocardiography) of cardiac dysfunction
Wherever possible, response to appropriate therapy for heart failure
ESC definition: Chronic Heart Failure
8. Aetiology of heart failureBromley Heart Failure Study: 136 cases aged < 75
9. Burden of heart failure 63,000 new cases each year in the UK
878,000 people suffer from definite or probable heart failure at any one time
40% of people will die within one year
Causes 5% of all deaths
One million bed days (2% of total)
Admissions projected to rise by 2% per year
11. The cost of heart failure is driven by inpatient care Heart failure is a very expensive condition – the estimated total annual cost to the NHS is £625 million per year, or around 1.8% of the NHS budget.
The cost of managing heart failure is largely driven by inpatient care costs. In England, heart failure currently accounts for around one million inpatient bed days, and this constitutes around 60% of the estimated £625 million annual cost of heart failure.
In addition, patients have frequent contact with primary care, requiring on average 11-13 contacts per year with the GP or other members of the primary care team.
By contrast, drug costs in heart failure account for a very small proportion of the total cost of care, around 9%.
The burden of heart failure is expected to grow over the next 20 or 30 years: hospital admissions for heart failure are expected to rise by 50% over the next 25 years.
Petersen S, Rayner M, Wolstenholme J. Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation, 2002.
Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 2002; 105: 2861?6.
Heart failure is a very expensive condition – the estimated total annual cost to the NHS is £625 million per year, or around 1.8% of the NHS budget.
The cost of managing heart failure is largely driven by inpatient care costs. In England, heart failure currently accounts for around one million inpatient bed days, and this constitutes around 60% of the estimated £625 million annual cost of heart failure.
In addition, patients have frequent contact with primary care, requiring on average 11-13 contacts per year with the GP or other members of the primary care team.
By contrast, drug costs in heart failure account for a very small proportion of the total cost of care, around 9%.
The burden of heart failure is expected to grow over the next 20 or 30 years: hospital admissions for heart failure are expected to rise by 50% over the next 25 years.
Petersen S, Rayner M, Wolstenholme J. Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation, 2002.
Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 2002; 105: 2861?6.
14. People with heart failure have impaired quality of life as a result of :
physical symptoms
adverse effects of treatment
psychological problems
social limitations
Quality of life is directly linked to functional ability in these patients.
15. Symptoms Breathlessness
Effort intolerance
Fluid retention
orthopnoea
PND
Palpitations
syncope
Fatigue
17. AHF Treatment Telemetry
Sit upright
High flow O2
Diamorphine 2.5-5mg
IV nitrate GTN 1-2mg/hr (If BP will tolerate)
IV frusemide
Consider NI ventilation
Consider inotropes
Goals of treatment
Stabilise physiology
Relieve symptoms
Look for underlying cause
18. Management algorithm for HF Establish patient has HF
Identify aetiology of HF
Identify concomitant disease relevant to HF
Assess severity of symptoms
Assess prognosis
Anticipate problems
Choose and tailor treatment
Follow up and modify treatment
19. Principles of drug management Evidence based
Aims – mortality / morbidity
Simple
Patient engagement
Routine
Optimisation
Cautions
20. Diuretics Loop diuretics, thiazide diuretics, potassium-sparing,
Symptom management
Monitoring – fluid status, U&Es, symptoms
Patient control
Problem solving
21. Ace Inhibitors LV dysfunction – research
Titrate to optimum dose
Monitor – BP + U&Es (potential side-effects)
Patient advise
Problem solving
22. Angiotensin Receptor Blockers LV dysfunction – intolerant of ACE 1
CHARM
Monitor
Patient advise
Problem solving
23. Beta Blockers Stable Heart Failure, on an ACE 1 / ARB
‘Start slow, go slow’
Monitoring
Patient education and engagement
Problem solving
24. Aldosterone antagonists Symtoms despite optimised therapy in LV dysfunction / LV dysfunction post MI
Monitoring
Problem solving
25. Digoxin Worsening/severe H.F. despite optimized therapy in LV dysfunction
Morbidity not mortality – reduce admissions
Management of AF
Monitoring
26. Nitrates Management of angina
Vasodilatation
Monitoring and review
(ACE 1 intolerant/contraindicated – with hydralazine)
Patient education
27. Symptom management Analgesics
Anti-emetics
Sedation
Depression & anxiety
Breathless management
Aperients
28. Co morbidities Arrhythmic management
Arthritis
Warfarin
Statins
Diabetes
29. Cautionary medication NSAIDs
Calcium Channel Blockers – except Amlodipine
Herbal medication – cod liver oil,
30. Importance of drug compliance Who can modify medications
Blood tests / Eye tests etc – amiodarone
Review
Tools
31. Patients understanding of heart failure 1.Inadequate knowledge of causes symptoms and consequences
Did not connect symptoms to CHF
Did not distinguish acute and chronic aspects of CHF
2.Did not see CHF as chronic disorder due to weak heart
3.Unable to recognise and address worsening symptoms
Did not see link between swollen ankles and CHF
Did not link action to symptoms
32. Mood in Heart Failure Depression
Prevalence ranged between 15%-51%
(Freedland et al. 2003)
Anxiety
Poor Data on Prevalence
Levels of psychopathology significantly higher in heart failure than healthy population Levels of depression vary, dependent on measurement, regardless known that higher than in age adjusted healthy populationLevels of depression vary, dependent on measurement, regardless known that higher than in age adjusted healthy population
33. Interventions for Mood Cognitive Behaviour Therapy
Problem Solving Interventions
Anti-Depressant Therapy
Typically Individual Based
38. Illness Adjustment in Heart Failure
The extent that an individual acknowledges and manages their illness to maximise physical, social and emotional functioning and hence optimise quality of life
Indicated by level of functioning, particularly social and emotionalIndicated by level of functioning, particularly social and emotional
39. Illness Adjustment in Heart Failure Cont.
Important Predictors:
Illness Cognitions (Time period, consequences, causes, symptoms, control)
Coping Strategies (Information seeking, reinterpretation, denial, seeking support, wish fulfillment, emotional expression)
Social Support
40. Adjustment Interventions to Improve Adjustment In Heart Failure: Non- Adherence:
Information is necessary but not sufficient
Illness Cognitions
Barriers to Change
Expectancies
Self-Efficacy
Adherence vs Self-Management
41. Coping Strategies:
Interventions to Improve Self-Management
42. Education and information What heart failure is
Diet
Weight management
Fluid status/balance
Smoking
Exercise
Activity
Prognosis
Health care status Energy conservation
Breathing
Drug therapy
Immunisation
Healthy living
Alcohol
Stress management
Relaxation
Effects and management
43. Living with heart failure Positive
Realistic
Control
Adaptation
Expectations
Fear
Support
44. Effects of deconditioning in heart failure:
Cardiac abnormalities
Ventilatory abnormalities
Abnormality of autonomic control
Other effects – social and psychological Benefits of exercise:
Improvement in Skeletal Muscles
Cardiac/Vasculature improvements
Ventilatory Improvements
Improvements in Autonomic control
Psychosocial improvements
45. Illness Adjustment in Heart Failure
The extent that an individual acknowledges and manages their illness to maximise physical, social and emotional functioning and hence optimise quality of life
46. Limiting effects of heart failure Reduced cardiac function / output
Muscle weakness, cachexia, wasting
Fatigue, lethargy
Impaired cognitive function
Altered mood
Respiratory function
47. Rehabilitation & exercise
Energy conservation
Pacing
Effects of deconditioning
Benefits
Function
Safety
48. Benefits of Exercise: Studies have shown many benefits of exercise in CHF patients. Some of these are:
Improvement in Skeletal Muscles
Cardiac/Vasculature improvements
Ventilatory Improvements
Improvements in Autonomic control
Psychosocial improvements
Single muscle resistance training can have a positive effect in the untrained contralateral limb 30.
Symptomatic improvement in CHF patients depends on resolution of muscle abnormality 28.
Even a small increase in exercise tolerance can dramatically reduce patients dependence thus making exercise therapy a cost-effective option of treatment8.
49. Benefits of exercise: An improvement in:
Skeletal Muscles
Cardiac/Vasculature Ventilatory Improvements
Autonomic control
Exercise also has an impact on a persons psychosocial staus
Improvements can be achieved with modest increase in exercise tolerance
50. Energy Conservation Definition: making the most of the body’s available energy and getting the most amount of work done using the least amount of energy
3 strategies:
Pacing
Co-ordinating breathing with daily activities
Work simplification
Application to daily activities
51. Pacing ……. “Rest before you get tired.”
Benefits:
Manageable breathing
Stay active every day
Good balance between activity and rest
52. Work simplification ‘Make the activities that need to be done during the day easier to do.’
Plan
Prioritise
Good posture
Organise the environment
Assistive equipment
53. Breathing Use pursed lip and abdominal breathing
Do not hold breath during activities!
Exhale during the most strenuous part of the activity and when bending the trunk
Inhale when lifting the arms up and when moving the arms away from the body
Adequate ventilation
54. Cachexia Caused by prolonged cardiac insufficiency and heart failure
Results in loss of muscle mass (Including cardiac muscle) and adipose tissue (fat mass)
Affects symptoms and exercise capacity
Features of malnutrition and Cachexia
Progressive weight loss
Poor immune response
oedema
Reduced tolerance to medical treatment
Increased risk of complications
Depression
Untimely death
55. Balance of good health model
58. It is important the exercise is frequent (3x week) and manageable outside a supervised environment
needs to fit into peoples lifestyle
needs to continue
needs to be regular
needs to meet their needs
60. NICE Guidelines
‘Good communication between healthcare professionals...’
Liaison
Chronic disease management strategies
Multi-disciplinary working
Role model
Education and resource
‘Your healthcare team should be listening to your feelings, fears, views and beliefs.’
Knowledge
Confidence
Support
Skills
rehabilitation
Palliation
61. NSF / NICE The NSF in CHD states that all patients diagnosed with heart failure should be offered treatments most likely to both relieve their symptoms and reduce their risk of death.
NICE (2003) also advocate the use of exercise as being both safe and effective in patients with CHF though offer little advice on implementation.
There is no single baseline factor that can be significantly correlated to outcome so it is not possible which patients may benefit most from exercise programmes from their clinical characteristics prior to commencing exercise .
Higher capacity after exe training may encourage patients to lead more active lifestyle which would maintain a higher peak VO2 long-term .
Exercise must be continued to maintain benefit.
62. NICE Guidelines
‘ should give you the information you ask for or need about heart failure, the treatments and the possible side effects’
Expert
Diagnosis and treatment
Protocols
Education tools
‘..should work in a constructive partnership with you and your family or carers at all times, including when decisions need to be made about your care.’
‘..should offer help and support to cope with any effects that chronic heart failure have on your daily life.’
63. Dyssynchrony Progressive ventricular remodelling