The Waikato Integrated Heart Failure Service (WIHFS)

1. The Waikato Integrated Heart Failure Service (WIHFS) Debbie Chappell CNS Heart Failure Taumarunui/Te Kuiti/Otorohanga/Te Awamutu

2. The Waikato Integrated Heart Failure Service Team • HF CNSs: • Julie Jay, Eileen Gibbons, Karyn Haeata,Debbie Chappell, Simona Inkrot, Catherine Callagher • Cardiologists: • Mark Davis, Gerry Devlin, Raewyn Fisher • Sonographers

3. HF in Aotearoa/NZ • 2 % Heart Failure prevalence in Western societies • HF Incidence is rising with an ageing population and the improved treatment and survival of heart disease • Median survival of 3.5 years after initial HF admission in NZ • One-year HF mortality rates after initial hospital admission are between 25 and 35% • Maori patients admitted with HF are significantly younger than NZ European: mean age 62 vs. 78 years McMurray et al., 2012; Wasywich et al, 2010; Schaufelberger et al., 2004; Wall et al., 2012

4. Refresher A&P

5. Definition Heart Failure is a clinical syndrome where the heart is unable to pump blood at a rate required by the body, patients present with some or all of the following features: • Symptoms typical of heart failure (breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling) AND • Signs typical of heart failure (tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly) AND • Objective evidence of structural or functional abnormality of the heart at rest (cardiomegaly, third heart sound, cardiac murmurs, abnormality on the echocardiogram, raised natriuetic peptide concentration)

6. Normal HF-REF HF-PEF

7. Some causes of heart failure • Coronary artery disease • Hypertension • Valvular heart disease • Cardiomyopathies • Endocrine disorders-thyrotoxicosis • Genetic conditions • Congenital heart disease • Inflammatory • Chronic arrhythmias • Also think of co morbidities – diabetes, obesity, COPD

8. Pathophysiology Compensatory mechanisms of acute heart failure • Sympathetic nervous system activation • Renin-angiotensin system activation • LV remodelling OUTCOME: • Vasoconstriction – Increased HR, SV leads to increased CO • Attempt to maintain cardiac output and vital organ perfusion – heart, brain, kidneys

9. Maladaptation • Compensatory mechanisms become “maladaptive” in chronic heart failure OUTCOME: • Excessive vasoconstriction • Increased afterload • Excessive salt and water retention • Electrolyte abnormalities • Arrhythmias

10. Investigations • Observations – TPR BP (lying/standing), weight, height BMI • ECG – old and new changes • Bloods – CBC, U&E, Cardiac enzymes, NT-pro BNP, LFT, Cholesterol, TFT • CXRay – old and new • ECHO- normal EF >55%, moderate – severe HF<40%

11. Pharmacological - Diuretics -ACEi -Beta-blockers -Other drugs Non pharmacological -fluid management -nutrition -physical activity -smoking -psychosocial support -other factors Treatment Options – medical vs intervention

12. Case studies • 75 year old female • History incr SOBOE (getting worse) • Bilateral pitting oedema • JVP +2, chest clear • History hypertension • Dip stick, LFT, U&E • NT pro BNP 400 pg/mL • Refer - ECHO normal LV, elevated filling pressures, HFpEF • Treatment options • 49 year old male • Bilateral oedema, pants tight • Appetite depressed • JVP normal, ascites, ? pulsatile liver • Jaundiced • Dip stick (bilirubin) • LFT - abnormal • NT pro BNP – normal • Renal – normal • Check ? Hepatitis, alcohol, blood transfusion

13. Aims of treatment / nursing role • Improve symptoms – fluid restrict, daily weigh, medication • Improve LV function – medication, medical intervention • Improve exercise tolerance – moving, pacing themselves • Improve patient education & self-management – HF booklet • Decrease hospital admissions - improve survival • End of life care

14. CNS led interventions for HF patients • Decreased hospitalisation, decreased number of events, readmissions and days in hospital • Improved survival • Cost effective • Improved self-care behaviour Stromberg et al., 2003; Phillips et al., 2005

15. Referral Criteria Inclusion: • Patients with possible heart failure and/or at high risk for heart failure in the community, e.g. previous MI, family history of cardiomyopathy • Patients readmitted for heart failure within 3 months • Heart failure patients with significant co-morbidities affecting optimisation of treatment • “Shared care” for end stage/palliative care Exclusion: • Lack of consent from patient • Acute coronary syndrome • Patients already under the care of a cardiologist, unless referred by this cardiologist (inclusion criteria must be satisfied) COMPONENTS OF WIHFS • Specialist clinics (CNS and cardiologists), Home visits, Telephone care • Patient and family/whanau education: heart failure knowledge and self-care • Clinical monitoring • Titration of heart failure medications in consultation with GP and/or cardiologist • Professional education/CME for other health professionals and community teams

16. Thank you Debbie Chappell – Taumarunui Te Kuiti/Otorohanga/Te Awamutu 0212419452 07 8785192 Questions?