Jules Grange HF Specialist Nurse Eastbourne DGH

1. Jules Grange HF Specialist Nurse Eastbourne DGH Cardiovascular Risk Assessment October 2010

2. Facts.... • Cardiovascular disease is the leading cause of premature morbidity and mortality in the UK • Effective prevention and treatment is a fundamental priority for the NHS • Early identification leads to early treatment • NHS Health Check programme NICE 2010

3. CHD Statistics CHD is the most common cause of premature deaths in the UK CHD is the most common cause of HF in westernised countries CHD causes approx 70% of HF cases in UK UK has one of the highest death rates from CHD BHF Heartstats 2006

4. BUT… Death rates from CHD have been falling since the late 1970’s 46% reduction for men under 65 in the past 10 years BHF Heartstats 2006

5. Racial and Ethnic Groups CVD is the leading cause of death for African Americans, Latinos, Asian Americans, Pacific Islanders, and American Indians African American women are at the highest risk for death from heart disease among all racial, ethnic, and gender groups CHD is less common in Black Caribbean and Chinese men compared to the general population. Chinese women have significantly lower levels of CHD than the general population. Source: Rosamond 2008

6. Women Receive Less Interventions to Prevent and Treat Heart Disease Less cholesterol screening Less lipid-lowering therapies Less use of heparin, beta-blockers and aspirin during myocardial infarction Less antiplatelet therapy for secondary prevention Fewer referrals to cardiac rehabilitation Fewer implantable cardioverter-defibrillators compared to men with the same recognized indications Sources: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005, Chou 2007, Hernandez 2007, Cho 2008

7. Risk factors for CVD 9 major risk factors account for over 90% of the risk of acute MI - smoking - abnormal lipids - hypertension - diabetes - obesity - diet - physical activity - alcohol consumption - psychosocial factors Smoking and abnormal lipids account for 2/3 of the risk INTERHEART study Lancet 2004

8. Incidence likely to increase Ageing population1 Advances in cardiac treatment which increase survival2 Projected number of Hospital admissions for HF 2011/12= 869,0003 38% die within 12 months of diagnosis4 Survival rates lower than breast or prostate cancer5 Heart failure in the UK References: 1. Bonneuxet al. Am J Public Health 1994 2. Kelly Circulation 1997 3. Gnoni et al (2001) 4. BHF CHD Stats: HF Suppl 2002 Ed 5. Stewart et al. Eur J Heart Failure 2001

9. Heart failure in the UK Reference: Stewart et al. Eur J Heart Failure 2001

10. The Donkey Analogy Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living…

11. SHAPE Study 29% of General Public viewed HF as ‘severe’ 67% wrongly believed that more people died from cancer 66% wrongly believed that more people died from HIV SHAPE Survey Results to the General Public Annual Congress of the European Society of Cardiology in Vienna, September 2003. www.heartfailure-europe.com

12. Problems with current HF management Sub-optimal medication at discharge1,2 Failure to emphasise non-pharmacological management2 Little patient/carer education HF symptoms not taught Daily weight not explained Lack of cardiac rehabilitation References: 1. Toal & Walker. Eur Heart J 2000. 2. Cited in Moser DK 2001.

13. Problems with current HF management Inadequate access to healthcare personnel1 Poor follow-up1 Non-compliance1 Reference: 1. Cited in Moser DK 2001.

14. Problems with current HF management Elderly patients are particularly vulnerable1 Co-existing conditions Poly pharmacy Cognitive/functional limitations Isolation & inadequate social support Financial concerns Anxiety & depression Reference: 1. Cited in Moser DK 2001.

15. Co-morbidities that may impact on the treatment of heart failure NICE, 2003

16. Problems with current HF management 64% of re-admissions caused by non-compliance1 54% of re-admissions are preventable2 Referencea: 1. Ghali J et al. Arch Intern Med 1988. 2. Michalsena et al. Heart 1998.

17. CHF patient cycle Decompensation Lack of follow-up No recognition of decompensation Lack of compliance Hospitalisation Home Stabilisation Additional medication No additional education No additional CHF management

18. Why are medications not optimised? Lack of knowledge/expertise Lack of time Difficult diagnosis Co-morbid conditions Lack of co-ordinated care

19. Optimal care Education Pharmacological management Non pharmacological management Patient empowerment Essential link for advice

20. Symptoms and signs of heart failure Common symptoms Common signs • Dyspnoea • Orthopnoea • Paroxysmal nocturnal dyspnoea • Ankle swelling • Fatigue • Exercise intolerance • Weight gain • Anorexia • Palpitations • Memory loss • Tachycardia • Raised JVP • Displaced apex beat • Right ventricular heave • Basal crackles • Wheeze • S3 • Oedema • Hepatomegaly • Ascites • Cachexia, muscle wasting

21. The Patients perspective... • I’m tired • No energy • I really need my fags to get through the day • Doctor says my blood pressure is ok • Those tablets make me pee all day • I hardly eat a thing! • I’m out of puff • I can’t get my shoes on • Things don’t work as well as they used to • …But then I am getting on a bit now!

22. Self Management Encourage daily weights Set targets for fluid intake as necessary Recommend low salt diet Maintain healthy weight Encourage daily exercise Reinforce benefits of medication Encourage flu/pneumococcal vaccination Promote smoking cessation Consider temporary increase in diuretics according to local protocol

23. Pharmacists role? • Obviously medication management • Look for other clues • Signposting to other health care providers • Supporting patients and families • Communication • Promoting healthy living and positive behavioural change

24. Invitation To sit in on hospital based Heart Failure Clinic Questions? jules.grange@esht.nhs.uk Tel 01323 417400 ext/bleep 4732