The Challenges and Opportunities of Improving Heart Failure Management in the Community.

1. The Challenges and Opportunities of Improving Heart Failure Management in the Community.

2. McIntyre et al (2002) • “Heart failure care is fragmented due to a lack of understanding between primary and secondary care.”

3. Guidelines “Rome wasn’t built in a day” • 1997 ‘The New NHS’ • 1998 ‘Saving Lives’ • 2000 NSF for CHD • 2011 NICE for CHF • 2004 GMS Contract • 2007 SIGN Updated Guidelines

4. Primary & Secondary Care 3 Recent Impacts • Movement of services out of secondary care • GMS contract for GP’s • Introduction of the role of Community Matrons Nicholson C, 2007

5. Movement of services out of secondary care • Hospital services congested, patient experience often poor, diagnostics, treatment and follow-up can be done in primary care. Nicholson C, 2007 • CHF management is likely to be shared between primary and secondary care NICE 2003 • CHF mortality and readmission is reduced by home/clinic-based specialist teams SIGN 2007

6. GP Contract for General Medical Services (GMS) • GMS Contract – 2004 • Payment by results, Quality and Outcomes Framework (QOF) • 3 Heart failure point indicators -LVSD1 = Register -LVSD2 = Diagnosis confirmed by echo. -LVSD3 = ACE Inhibitors prescribed Nicholson C, 2007

7. Health Care Commission • Effective diagnosis • Evidence based treatment and monitoring • MDT approach with educational support • Are services having positive effect • Scored weak/fair/good/excellent

8. Heart Failure Service • Commenced April 2009 • Team = HFNS 22.5 hrs x 2 GPwSI Dr Andy Gallagher Secretary 15 hrs • Referral Criteria = LVSD Evidence • Catchment area=Lancaster,Garstang, Morecambe & Carnforth (Ash Trees) only • Fax referral, from primary or secondary care, by all staff

9. What is Heart Failure?

10. “Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support the physiological circulation”, NICE (2003).

11. How Big is the Problem? • Around 900,000 people in the UK today have heart failure. • Increases steeply with age. • 40% of heart failure patients die within a year but thereafter mortality is less than 10% per year. • A GP will look after 30 patients with heart failure and suspect a new diagnosis of heart failure in perhaps 10 patients annually.

12. £45 million per year with an additional £35 million for GP referrals to outpatient speciality • Drug therapy costs the NHS around £129 million per year. • Heart failure accounts for 2% of all NHS bed days and 5% of emergency admissions to hospital. • Projected to rise by 50% over the next 25 years, (Gnani & Ellis, 2001).

13. Heart failure costs the NHS £716 million per year. • Readmission rates are as high as 50% in the elderly six months following discharge. (NICE, 2003)

14. So Why Is Heart Failure So Important? Extremely Debilitating Worse prognosis than most cancers Unpredictable terminal trajectory Accounts for 4% of all deaths Largest single reason for bed days due to chronic condition

15. Chronic Heart Failure (CHF) • CHF is a debilitating long-term illness and exerts a heavy burden upon both the individual and society. Stewart S & Blue L 2001 • Prevalence is expected to continue to rise over next several decades due to decreased mortality from cardiovascular disease and the growth of the elderly population ESC 2001

16. The NSF CHD Standard 11 (Heart Failure) • Help patients to live longer and achieve a better quality of life. • Help patients with unresponsive heart failure to receive appropriate palliative care support.

17. Ischeamic Heart Disease Myocardial Infarction Uncontrolled hypertension Valvular disease(particularly Aortic & Mitral Valves) Cardiac Arrhythmias Myocarditis Toxic substances – Alcohol/Medications/Viral Anaemia Hyperthyroidism Pregnancy Congenital Heart Disorders Signs Pulmonary Crepitations Pleural Effusion Oedema, Ascites Raised JVP Valve Sounds Symptoms Fatigue SOBOE Orthopnoea Acute SOB Loss of appetite Weight gain Causes of Heart Failure

18. The 3 Elements of HF • The initial injury • Impairment in function • Abnormal circulatory response

19. Cardio-Renal model Impaired ability of the heart to contract Impaired supply to the kidneys Sodium and water retention Peripheral oedema-Heart Failure

20. Neurohormonal Model • The basis for all heart failure treatment today • Heart Failure develops and progresses because of NS • Activated by the initial injury to the heart • Exerts deleterious effects on the heart and circulation, independent of the haemodynamic status of the patient

21. The cardiac neuroendocrine effect • RAAS • Adrenergic activation • ADH • Endothelins • Natriuretic peptides

22. How the heart reacts • The BP increases • The size of the heart increases • The heart becomes stiff and rigid • The pulse rate increases • Cardiac output falls • Hypertrophy • Atherogenesis • Vessel Wall Fibrosis

23. But • What happens when there is too much fluid in the body • BNP

25. Systolic or Diastolic HF • 60% of Patients thought to have LVSD • 40% Diastolic • No clinical trials completed for diastolic so management very much diuretic therapy due to potential for fluid retention. • More likely to be admitted to hospital • LVSD-Proven clinical trials base treatment with clear outomes • Charm, CIBIS, AIRE, Rales

26. Treatment Options • Diuretics (Symptom Control) • Inotropes (Rarely Used) • Vasodilators (Symptom Control) • Betablockers (Improve Outcomes) • ACE therapy (Improve Outcomes) • Spironolactone (Improves Outcomes) • Digoxin

27. Basic Management Take medications Restrict oral fluids 1.5 – 2 litres daily Salt-free diet Weigh daily Exercise, non-smoking, alcohol limits, healthy diet, weight management, etc.

28. Cardiac Resynchronisation Therapy (CRT) & Internal Cardiac Defibrillators (ICD) Widespread use NICE 2003 guidelines ICD management in palliative care.

29. Achieving Cardiac Resynchronization Right AtrialLead Left VentricularLead Right VentricularLead Goal: Atrial synchronous biventricular pacing Doug Smith:

30. ICD Shock delivered in pulseless Ventricular Tachycardia (VT) or Ventricular Fibrillation (VF) Cardiac arrest not to be confused with heart attack.

31. New York Heart Association Classification of Heart Failure Class 1–No limitation during ordinary activity Class 2–Slight limitation during ordinary activity Class 3–Marked limitation of normal activities without symptoms at rest Class 4–Unable to undertake physical activity without symptoms. Symptoms at rest. The Criteria Committee of the New York Heart Association 1973, Stewart & Blue 2004

32. Heart Failure Service Aims • Optimal medical therapy • Prevent rehospitalisation • Increase functional ability • Improve quality of life • Improved healthcare outcomes • Reduce mortality rates • Reduce outpatient referral • Improve patient education • Treat unstable patients Bosson O, 2004

33. Local Strategies • Patient focused in order to empower an active patient role. • Improved liaison between primary and secondary care to provide a seamless service. • Access to diagnostic services. • Help to identify inpatients who may benefit from the service. • Improved aftercare to prevent readmission.

34. Need to be underpinned By • The ability to identify as many patients as possible who could benefit from the service. • Confirmed diagnosis. • Managed within an area convenient to them. • Motivation to review them regularly “Ultimately the more the patient understands their condition the better their quality of life”, (BHF, 2007).

35. The Role of the Heart Failure Nurse • Care and advice to patients across a variety of settings. • Decrease hospital admission and readmission rates. • Improve quality of life. • Monitor patients conditions, readjusting their medication when appropriate. • Advise on lifestyle changes. • Provide emotional support.

36. Work in collaboration with MDT colleagues. • Provide education to colleagues. • Ensure service is audited effectively. • Help to develop heart failure register. • Utilise guidelines to help guide care. • Input from local hospice for heart failure patients. • Educate patients • Direct contact for advice

37. So how do we go about this?

38. See patients in both primary and secondary care settings. • Provide support in the commencement of medication as well as self management. • Follow up home visits. • Telephone contact. • Regular review within clinics. • Liase with MDT colleagues. • IT

39. Palliative Care Continue medications that assist cardiac function for as long as possible ACE/ARB II. eg Ramipril, Beta-blockers eg Bisoprolol, Diuretics eg Furosemide, Aldosterone-antagonist eg Spironolactone Diuretic therapy IV should be considered Morphine

40. The typical Heart Failure Trajectory

41. Palliative Care Cont. All palliative care but Continue diet and fluid restrictions Observe weight recordings Consider ICD device

42. From Exercise……… • Previously HF used to considered an absolute contra-indication to participation in exercise prescription • Encourage regular aerobic and/or resistive exercise – may be most effective when part of exercise programme. NICE 2003 • Evidence of reduced mortalityExTraMATCH 2004 _

43. …..to Palliative care. “Suddenly aborting heart failure services and transferring to palliative care is neither sensible nor preferable. Patients benefit from the support of both, based on individual needs and choices.” Nicholson C, 2007

44. Opportunites • To make a real difference • To develop a robust service for the future • To promote CHF management as a community speciality

45. Referral Criteria • Take referrals from medical staff, ward areas, GPs and community staff.

46. North Lancashire Teaching Primary Care Trust HEART FAILURE SERVICE Please refer North Lancashire Teaching Primary Care Trust patients with SYMPTOMATIC left ventricular dysfunction or Diastolic Heart Failure for follow up by the heart failure service. We endeavour to carry out the initial contact assessment within 7 days. Heart Failure Service Team Rob Sharkey Heart Failure Specialist Nurse Sue Leveridge Heart Failure Specialist Nurse Dr Andrew Gallagher GPwSI Please fax referrals to 01524-61443 Contact details Tel 01524-61443 Rosebank Medical Practice, Ashton Road, Lancaster LA1 4JS robert.sharkey@northlancs.nhs.uk susan.leveridge@northlancs.nhs.uk andrew.gallagher@gp-p81056.nhs.uk This is an NLPCT service and we accept referrals from practices in Lancaster, Morecambe, Carnforth (Ash Trees), and Garstang (Windsor Road and Landscape Surgeries)

47. Started with this

48. We might not make this

49. Development of a local service, taking into account local needs and wishes. • We don’t have all the answers, are not the experts, but seek to deliver quality of care to patients to improve quality of life and life expectancy.

50. Case Study • 72 yr old female with breathlessness, fatigue leg oedema.Diagnosed with Aortic stenosis and had TAVI 6 month previous. Chair bound due to breathless state and fluid. Exercise capacity 5 yards. NYHA 4 • Ref made as palliative care from consultant and GP • Ramipril 1.25mg/Bisoprolol 1.25mg/Frusemide 40mg. • 1st visit-increased Ramipril to 2.5mg, changed to Bumetanide 3mg, started nutritional drinks. HF Education. • 2nd visit-Ramipril increased 5mg, added ISMO 10mg BD & Oramorph 2.5mls prn, LTOT. • 3rd visit-Bisoprolol increased 2.5mg, added Spironolactone 25mg. • 4th visit-Ramipril to 10mg • Weight loss of 16lbs, EC 100 yrds, No fluid excess. Bumetanide 1mg, O2 not required. • Feels back to pre illness state, weight gain naturally. NYHA 2/3 • Renal function stable. • Follow up 3 monthly