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Chronic Heart Failure GP Clinical update 11/11/09

Chronic Heart Failure GP Clinical update 11/11/09. Dr Paul Armitage GP Heart Failure Specialist, Dorset PCT Tracey Dare Heart Failure Nurse Specialist, DCH. Chronic Heart Failure.

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Chronic Heart Failure GP Clinical update 11/11/09

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  1. Chronic Heart FailureGP Clinical update 11/11/09 Dr Paul Armitage GP Heart Failure Specialist, Dorset PCT Tracey Dare Heart Failure Nurse Specialist, DCH

  2. Chronic Heart Failure “There is no disease that you either have or don’t have – except perhaps Sudden Death or Rabies. All other diseases you either have a little or a lot of” Geoffrey Rose

  3. Chronic Heart Failure- setting the scene • Common 1-2%of the population • Costly 1-2% of NHS budget • Disabling symptoms have large impact on quality of life • Deadly mortality 30% at 12 months but improving steadily • Increasing ageing population/more effective treatment for CHD

  4. What is Heart Failure – key facts • Heart Pump Inefficiency – either primarily a disorder of filling or of emptying (Tinsley R Harrison, 1950) • Most common cause is LV muscle damage • Various conditions may predispose to, or cause, such muscle damage

  5. Guess who?

  6. Causes of Chronic HF (UK only – Fox et al, European Heart Journal 2001) • Coronary Heart Disease 52% • Chronic hypertension 4% • Idiopathic 13% • Valvular dysfunction 10% • Cardiac arrhythmias 3% • Alcohol 4% • Other 4% • Undetermined 10%

  7. Prevalence • CHD increasing • Ageing population • Better CHD acute phase care • Better CHF management • West Dorset Population - prevalence estimate 4,500 (sex & age specific calculations, 2002)

  8. Incidence • 1- 4 new cases per 1000 population each year • Incident rate rises to more than 10 cases per 1000 in those aged 85 years and over • Male:female = 2:1 • West Dorset population - incidence estimate 330 new cases per year (sex & age specific calculations, 2002)

  9. Guess who ?

  10. Mortality • Mild – moderate CHF – 20% at 1 year • Severe - >50% at 1 year • Survival all classes – 30% at 8 years • 80% mortality in men within 6 years of diagnosis • Class II – sudden death risk

  11. Health Service Use • HF accounts for 5% of all hospital admissions • Patients frequently admitted • Bed occupancy average 20 days each admission • £360 million (hospitalisations = 59.5%)

  12. Guess who?

  13. Why so difficult? • Symptoms non-specific • Clinical signs insensitive • Definition of heart failure disputed • Poor primary care access to cardiac investigations eg BNPs and echocardiography

  14. Conditions presenting with similar symptoms • Obesity • Chest disease • Venous insufficiency in lower limbs • Drug induced ankle swelling (calcium channel blockers) • Drug induced fluid retention (NSAIDs) • Hypoalbuminaemia • Intrinsic renal or hepatic disease • Pulmonary embolic disease • Severe anaemia or thyroid disease • Bilateral renal artery stenosis

  15. Symptoms – may not be terribly helpful! • Shortness of breath on exertion • Decreased exercise tolerance • PND • Orthopnoea • Ankle swelling

  16. Guess who?

  17. Clinical signs • The most specific signs are: • Laterally displaced apex beat • Elevated JVP • 3rd heart sound • Less specific signs: • Tachycardia • Lung crepitations • Hepatic engorgement • Peripheral oedema

  18. Investigations • 12 lead ECG • Chest X-ray • FBC, U&E, TFT, LFT, glucose, lipids, urinalysis, peak flow • BNP where available • Echocardiography (open access available locally) • NB: If ECG is normal - it is very unlikely that the diagnosis is heart failure. Same for BNP

  19. Guess who?

  20. How useful is BNP? • 96% as useful as a panel of cardiologists • NB CTR on CXR is only 79% as useful as a panel of cardiologists • (the gold standard was an expert panel diagnosis blinded to BNP results) • Lancet 1997; 350:1349-53

  21. To diagnose Heart Failure 3 things are essential: • 1. Patient • 2. BNP • 3. ECHO Awaiting new NICE guidelines (PCTs beware!)

  22. Guess who?

  23. CHF management • Establish cause (angiography, CDM screen) and treat appropriately • Evidence based pharmacological treatments (ACEi, Beta blockers, aldosterone antagonists) • Device therapy (CRT-P, CRT-D) • Self management/ lifestyle advice • Heart Failure Services • Liaison/ onward referrals (CKD team, PPM techs, arrhythmia nurse, Smoke Stop, Dieticians, Cardiac Rehab, pharmacists, Community Matrons, PC Team)

  24. ACE inhibitors • HOPE = Heart Outcomes Prevention Evaluation Study • CONSENSUS = Co-operative North Scandinavian Enalapril Survival Study • SOLVD = Studies of Left Ventricular Dysfunction • All grades of CHF unless specific contraindications • Cautions • Significant renal dysfunction, bilateral renal artery stenosis, symptomatic/ severe asymptomatic hypotension, K+ supplements/ K+ sparing diuretics

  25. ACE inhibitors

  26. Cardio-selective Beta blockers • Undisputed evidence. Recommended in NICE guidelines • Reduction in HF exacerbations • Reduction in hospitalizations and bed days • Improved symptoms/ NYHA class/ QOL • Reduces mortality

  27. Beta blocker Trials • CIBIS (1994) and CIBIS II (1999) (The Cardiac Insufficiency Bisoprolol Study) • COPERNICUS (CarvedilOl ProspEctive RaNdomIzed Cumulative Survival) 2001 • CAPRICORN (Effect of Carvedilol on outcome after myocardial infarction in patients with left ventricular dysfunction) 2001 • SENIORS (Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with heart failure) • Undisputed evidence from various studies

  28. Beta blockers • Beta-blocker titration • Bisoprolol 1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg • Carvedilol 3.125mg BD, 6.25mg BD, 12.5mg BD, 25mg BD • Nebivolol 1.25mg, 3.5mg, 5mg, 7.5mg, 10mg

  29. Aldosterone antagonists • Consider for moderate to severe HF already on ACEi and loop diuretic • Spironolactone 25mg (increase to 50mg if necessary) • Epleronone 25mg (increase as above) NB licensed for post MI only but consider for all patients if Spironolactone causes hormonal side effects • NB Renal function monitoring

  30. Other pharmacological considerations • Co-morbidities/ polypharmacy • Compliance and understanding • Blister packs • Timely interface communication of drug dose changes

  31. Heart Failure Service Dorset County Hospital • Set up in response to NSF 2001 • Aim to optimise pharmacological therapy through series of out patient visits • Patient education (BHF Heart Failure Plan). Medication concordance and treatment compliance. • Monitoring • Support & point of contact • Interface link. Onward referrals

  32. Heart Failure Service Dorset County Hospital • Clinic based intervention only • x1 Full time HF Nurse Specialist • GP Heart Failure Specialist x2 sessions per week • Service provision includes:- • Dorset County Hospital (x2 per week, plus some in-patient cover dependant on availability) • Weymouth (x2.5 per week) • Bridport Community Clinic (x1 per week)

  33. Heart Failure Service Dorset County Hospital • Service population 229,836 • Estimate 4,500 prevalence and 330 new patients per year • Total referrals up to end of year 8 = 1489 (187 per year) • 301 patients on present active caseload (as of 3/11/09)

  34. Heart Failure Service Dorset County Hospital

  35. Heart Failure Management • Complex condition to manage • Timely recognition/ diagnosis/ treatment of underlying causes results in best outcomes and more cost effective in the long run • Open access echo service – direct route of referral to the HF service • Pharmacological therapy is only part of the management but a big part of the heart failure service work

  36. Heart Failure Service • Referrals from GPs can be accepted if the patient already has a confirmed diagnosis and previously known to Cardiology Consultants • Open access ECHOs – if heart failure confirmed this will result in direct referral to the service for assessment/ further investigations and formulation of management plan • Limited service provision (no domiciliary service) but willing and happy to help where we can. To discuss any patient on an individual basis – please contact us via Dorset County Hospital 01305 255610 (24 hour voicemail) Tracey.Dare@dchft.nhs.uk

  37. Q. Why are they no longer with us?

  38. Answers: • 1. Late diagnosis • 2. GP didn’t have access to BNP or Heart Failure Services • 3. Beta blockers not available in Chechnia • 4. Too much cocaine/ alcohol

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