Chronic heart failure (Left ventricular systolic dysfunction)

1. Chronic heart failure(Left ventricular systolic dysfunction) Key slides

2. What is the prognosis, and what are the costs to the NHS?McKelvie R. Clinical evidence. Search date 2007; The Information Centre, National Heart Failure Audit, 2007 5-year mortality 26–75%: One-third of deaths preceded by a major ischaemic event 25–50% are sudden deaths, presumed mainly due to ventricular arrhythmias Better prognosis with preserved LV systolic function Costs to the NHS: Providing services to patients with HF costs the NHS an estimated £625 million per year HF places a significant demand on hospital facilities and resources through hospital emergency admissions and re-admissions. It accounts for 5% of medical admissions, while the re-admission rate for HF has been estimated to be as high as 50% over 3 months

3. Diagnosis of heart failure Individual signs and symptoms are poorly predictive of HF It is important to exclude other conditions that may masquerade as HF A patient is unlikely to have HF if they have a normal ECG and normal BNP levels Echocardiography if BNP or ECG abnormal Algorithm for diagnosis NICE guideline (2003)

4. Improving the quality of carewww.heart.nhs.uk/heart/Portals/0/docs_2008/HF_commissioning_guide.pdf Treatment: elements of best practice Behavioural modification — dietary changes, exercise, smoking cessation, reduced alcohol consumption and self-management Pharmacological therapy—the right drugs at the right dose sustained over time, eg ACE inhibitors, beta blockers, diuretics and digoxin as necessary Interventional procedures—appropriate in selective patients. These may include cardiac resynchronisation, internal defibrillator (CRT/CRTD), revascularisation, restorative surgery, transplantation and involve heart failure rehabilitation

5. Algorithm for the drug treatment of HFMeReC Bulletin Vol 18 No 3 February 2008 Diuretic therapy is likely to be required to control congestive symptoms and fluid retention Digoxin is recommended as an add-on treatment for patients in sinus rhythm who remain symptomatic despite optimised treatment CHF Diagnosis Start ACE inhibitor and titrate dose in all patients (a) Add licensed beta blocker when stable and titrate dose (b) a) ACE inhibitor-induced cough rarely requires treatment discontinuation but in the small minority in whom it does, an A2RA may be substituted. b) In those already taking a beta blocker (eg atenolol) recent reviews suggest that switching to a beta blocker licensed for CHF may be a better option, as evidence suggests the benefits of beta blockers may not be a class effect. c) The SIGN guideline recommends use of candesartan based on evidence from the CHARM-Added study. d) The SIGN guideline considers eplerenone as an alternative in patients who experience the side effect of gynaecomastia with spironolactone. If still symptomatic seek specialist advice Consider adding in an A2RA (c) and titrate dose If still symptomatic stop the A2RA Add in spironolactone and titrate dose (d)

6. ACE inhibitorsESC HF Guidelines 2008 ‘Treatment with an ACEI improves ventricular function and patients, well-being, reduces hospitalisation for worsening HF, and increases survival’ Key trials: SOLVD-Treatment: mild to moderate HF, enalapril vs. placebo Mortality RRR 16% (NNT=22 over 41 months) (Hospital admission for worsening HF RRR=26%) CONSENSUS: severe HF, enalapril vs. placebo Mortality RRR 27% (NNT=7 over 6 months) Supported by a meta-analysis of small short-term placebo-controlled RCTs, which showed a clear reduction in mortality within only 3 months. These also showed that ACEIs improve symptoms, exercise tolerance, quality of life and exercise performance

7. A2RAs in heart failureLee VC, et al. Ann Intern Med 2004; 141: 693-704; EBM 2005; 10: 76 n=38,080 Meta-analysis of 24 RCTs over 1–41 months ‘[A2RAs] are great drugs [for heart failure]; their misfortune is that ACE inhibitors are too’ ‘Fewer data supports [A2RAs] and [A2RAs] cost more’ ‘[A2RA] manufacturers hoping for evidence that [A2RAs] should be first choice over an ACE inhibitor are probably close to giving up’

8. Adverse effects of A2RAs plus ACEIs in symptomatic LV dysfunctionPhillips CO, et al. Arch Intern Med 2007;167:1930-1936

9. Beta blockers NICE Full Guideline 05, 2003; SIGN Guideline 95, 2007 Increase life expectancy and reduce hospitalisation in HF due to LV systolic dysfunction Benefits seen with beta blockers with different pharmacological properties 4 have evidence of effectiveness (3 licensed — bisoprolol, carvedilol, nebivolol; 1 unlicensed — metoprolol succinate) Beta blockers licensed for use in HF should be initiated in patients with HF due to LV systolic dysfunction after diuretic and ACE inhibitor therapy (regardless of whether or not symptoms persist) Patients who develop HF due to LV systolic dysfunction and who are already on treatment with a beta-blocker for a concomitant condition (eg angina, hypertension) should continue with a beta blocker — either their current beta blocker or an alternative licensed for HF treatment

10. Spironolactone in heart failureNICE Full Guideline 05, 2003; Pitt B, et al. N Engl J Med 1999;34:709–717 In NYHA III–IV the addition of low-dose spironolactone increases life expectancy: Hospitalisation is also reduced N=1663 DB RCT in NYHA III-IV, LVEF <35%, on ACEI: Spironolactone 25mg daily vs. placebo for mean 2 years Low beta-blocker use (11%) but similar benefits in this group Reduced death: 35% vs. 46%, RR 0.70 (0.60 to 0.82) NNT 9 No difference in severe hyperkalaemia (2% vs. 1%, P=0.42) Gynaecomastia increased: 10% vs. 1%, NNH 11, P<0.001 NICE recommends its addition to patients with HF who remain symptomatic despite optimal medical therapy (with diuretics, ACEIs, BB and perhaps digoxin)

11. Digoxin in patients with heart failure ESC HF Guidelines 2008; NICE Full Guideline No.5, 2003 In patients who are in sinus rhythm, NICE recommends digoxin for those who worsen or remain symptomatic despite ACEI, BB and diuretic treatment In patients with symptomatic HF and AF, digoxin may be used to slow a rapid ventricular rate In patients with AF and an LVEF <40% should be used to control heart rate in addition to or prior to a beta blocker In the long term, a beta blocker, either alone or in combination with digoxin, is the preferred treatment for rate control (and other clinical outcome benefits)

12. CHF treatment summary Educate and inform patients and carers: The condition, medicines, weight, fluids, diet, salt, nutrition, exercise, smoking, sex, vaccination and travel Apply the evidence from the trials to our patients: These interventions save lives, improve quality of life and reduce hospital admissions NICE algorithm for major drug (ACE inhibitors, beta blockers +/-diuretics, digoxin) plus: Spironolactone (eplerenone as alternative if gynaecomastia is a problem) or an A2RA in addition for patients who are symptomatic despite optimised treatment with an ACEi and beta blocker Statins, aspirin (or warfarin) as indicated for other conditions/risk factors Consider ISDN and hydralazine in African-American patients or where ACEIs and A2RAs not tolerated or contraindicated Amiodarone for specialist consideration

13. CHF management summary Manage comorbid conditions Check for and manage atrial fibrillation Recognise and respond appropriately to: Renal failure Anaemia Depression Plan for palliative care needs Improve the quality of care Individually tailored multidisciplinary management plan agreed between primary and secondary care, with support from nurses, pharmacists and local cardiac support networks Services for CV prevention, diagnosis, treatment and end of life care should be audited for compliance with NICE guidance (HF and CV risk assessment) and steps taken to address shortfalls