Protected learning Event : Better Outcomes for Patients with Heart Failure 13th January 2009 Sheffield Wednesday Foot

1. Protected learning Event :Better Outcomes for Patients with Heart Failure13th January 2009Sheffield Wednesday Football Club

2. GP Experience of the Sheffield Heart Failure Pathway, new QOF and its implications Dr Brian Hopkins Whitehouse Surgery Sheffield GP member of Sheffield Cardiac Commissioning and Planning Group

3. The Making of the Pathway NICE Heart Failure Guideline 2003 www.nice.org.uk/CG5 Sheffield Heart Failure Guideline 2003- last updated 2007 http://nww.sheffield.nhs.uk/policies/cvd.php 18 week Commissioning Pathway 2007 Sheffield Pathway 2008 NICE update 2009?

4. Cardiac Echo Open Access to echo for 10 years Current waiting time 3 weeks Improved cardiac echo reports Improved post-echo follow-up of newly diagnosed heart failure patients to increase patients on optimal therapy.

5. Miss Breath �aged 71 CHD Previous MI with VF arrest PCI Hyperlipidaemia Diabetes Hypertension

6. Echo Report Interpretation Summary �left ventricular systolic function appears mildly impaired� Sonographers Report too much to quote

7. Where did that leave us? Patient returned to GP No left ventricular systolic dysfunction (LVSD) -no new treatments Continued management of co-morbidities. Stop smoking! Arrange spirometry

8. Hospital and Community Cardiology led Heart Failure service across STH Hospital and Community based Heart Failure Nursing Services Cardiac Rehabilitation launched for patients with heart failure

9. Quality and Outcomes Framework Current QOF Heart Failure indicators for echo and ACEI/ARB use. New QOF indicator for beta blocker use in confirmed LVD from April 2009.

10. Shared Challenges Ensuring appropriate follow-up and treatment Expanding primary care based provision of HF services Improved end of life care in HF including implementation of Preferred Priorities for Care

12. Action Points 1. See the new Sheffield Heart Failure Pathway 2. Start using new echo referral forms 3. Explain to any absent colleagues re opt out box 4. Start to identify patients with LVSD suitable for B blockers For guidance on starting them refer to www.gptraining.net/protocol/cardiovascular/lvsd.htm

13. Guidelines for treatment of patients with LVSD (Left ventricular systolic dysfunction)( thanks to Ollie Hart) Background -only 50% of heart failure patients have LVSD (others = valvular, Diastolic (often hypertension causes this through LV hypertrophy), AF related, right sided) -ECG good at ruling out LVSD (negative pred value 98% if no major abnormality) -Diagnosis must be confirmed by ECHO, or specialist (QOF) Lifestyle- keep salt to minimum, stop smoking, exercise Ok in stable state

14. Medical Treatment (new DES is for B-blocker treatment - �35/ patient ?be paid) BUT REMEMBER BEFORE STARTING b-BLOCKER CONSIDER; diuretics for fluid overload (with reg u+e) Ace/ ARB start low (lisinopril 2.5mg)� titrate up to max tolerated (eg lisinopril 20mg) � QOF requirement Patients must be stable and not severe heart failure (NYHA 4 -symptoms at rest, discomfort on minimal activity) B-blockers in mild/mod LVSD shown to reduce mortality by 35% Care with B-Blockers in asthma/COPD/PVD

15. WHEN STARTING: only Bisoprolol/ Carvedilol licenced for LVSD (bisoprolol cheaper) Start low dose � bisoprolol 1.25mg (1/4 5mg generic tablet) Titrate at 2 week or more intervals, doubling dose, aim for 10mg od IF THEY DEVELOP CHF WHILE TITRATING: mild, give diuretics, consider halving dose if not responding mod, diuretics, half dose and review severe stop and admit For more detailed information see www.gp-training.net/protocol/cardiovascular/lvsd.htm