Heart Failure: From Failure to Success Dr. Alison Seed Consultant Cardiologist
Jan 11, 2016
Heart Failure: From Failure to Success
Dr. Alison Seed
Consultant Cardiologist
Failures?
• In diagnosis
• In routine management
• In advanced management
₤ To address the personal AND financial burden
Diagnosis...........
Prevalence>45yrs
National (expected)
2.3%
NationalBlackpool PCT (recorded)
1.8%(0.19-5)
1.Pushing the boundaries: Improving services for people with heart failure. HCC(CHAI ) 20072. State of healthcare: Improvements and challenges for services in England and Wales. HCC (CHAI) 20073. Blackpool GP HF register data: Brian Harrop, Blackpool PCT
MORTALITY BENEFIT OF BETA-BLOCKERS AND ACE-INHIBITORS IN CHF TRIALS
0
2
4
6
8
10
12
14
16 SSOLVD (1991) CIBIS II
MERIT-HF (1999)
diureticdigoxin
diuretic digoxin ACE-I
diuretic digoxin ACE-I
diureticdigoxin ACE-Ibeta-blocker
% d
eath
at
1 ye
ar
Routine management..........
Advanced management........
Implant rate / million population / year
USA
average
EU
average
UK
target
UK
average
Lancs. South
Cumbria 2006
ICD 610610 160160 100100 4646 2828
Bi V
PPM275275 7575 140140 5656 5858
Personal and financial burden...
Poor prognosis– 10-50% mortality per year
Poor quality of life– Poor exercise tolerance– >30% depressive illness
Frequent hospital admission– 5% of acute medical admissions– 40% death /readmission in one year
Long length of stay– > 8 days– 2% of in patient bed days
2% total annual NHS expenditure
CostCost
Hospital admission length of stay
Healthcare Commission 2007
• HF diagnostic services poor − Diagnosis difficult because symptoms non specific and physical
signs not obvious− Early diagnosis leads to appropriate life saving and symptom
reducing treatment
• Limited access to heart failure specialists− Need to target advanced treatments at high
risk patients
₤ Rates of hospitalisation remain high
Healthcare Commission. Pushing the boundaries: improving services for people with heart failure. London Healthcare Commission, 2007
Are we offering..........
Advanced Care or
Palliative Care
........... to our Patients with Heart Failure?
Currently (2009)….
Inequitable care
Only for the symptomatic patient seeking help
No more than Crisis management for the majority
Palliative Care that could be better !!
National drivers
Quality Outcomes Framework
‘Advancing Quality’ (NW SHA)
National HF database
Darzi report– Equitable, efficient, patient centred care– Health improvement (outcomes and quality)– Adherence to best practice (NICE, NSF)
Financial climate– Avoid hospital admission– Manage chronic disease in primary care
Our aim….‘Best care’ whenever and wherever patients require it ............
Not currently seeking attention
– Not yet diagnosed
– With confirmed diagnosis
New presentation
− In Primary Care with symptoms
Hospital admission(s)
− With severe heart failure
Our aim....
To demonstrate that optimal care is cost
saving...................
Failures?
•
• Routine management
• Advanced management
Diagnosis
Definition: The first problem
European society of Cardiology:
‘typically breathlessness or fatigue, either at rest or during exercise, or ankle swelling;
and objective evidence of cardiac dysfunction at rest (usually on
echocardiography)’
BLACKPOOL FYLDE AND WYRE HOSPITALS NHS FOUNDATION TRUST
LANCASHIRE CARDIAC CENTRE
Improving Diagnosis and Outcomes in Chronic Heart Failure
PROPOSAL 1
Patients presenting with breathlessness and patients on the listed chronic disease registers, attending for routine review, should be asked to complete an NYHA questionnaire while waiting to see the practice Nurse / doctor. Those whose answers suggest that they are in NYHA II or above should have a BNP test and be considered for referral to the one stop Heart Failure Diagnostic Clinic (HFDC) or open access echocardiography service.
NewYorkHeart Association
NYHA > IIFurther investigation required
Class Symptom
1 No limitation Ordinary physical activity does not cause tiredness, breathlessness, chest discomfort or palpitation (an unexpected awareness of your heartbeat).
2 Slight limitation You are comfortable at
rest but physical activity causes some tiredness, breathlessness, chest discomfort or palpitation (an unexpected awareness of your heartbeat).
3 Marked limitation You are comfortable at
rest, but everyday activities cause marked tiredness, breathlessness, chest discomfort or palpitation (an unexpected awareness of your heartbeat).
4 Inability to carry out any physical activity without discomfort
You have significant breathlessness or chest discomfort at rest. Any physical activity causes your symptoms to get worse.
BNP
Brain-type Natriuretic Peptide (BNP) is a hormone, secreted in the ventricular myocardium during periods of increased Atrial and ventricular wall tension
It is the most powerful marker of cardiovascular morbidity and mortality including sudden death
An elevated BNP indicates that the heart or kidneys are not working well but does not tell exactly why
NICE Guidance 2010
HIGH (>100)
‘VERY HIGH’ (>400) poor prognosis
Symptoms of HF
Previous MI?
Refer for urgent Echo and
Specialist assessment (within 2 weeks)
YES Check BNP
NO
Refer for Echo and specialist
assessment routinely
Prescribe Beta blocker and ACE inhibitor – use clinical judgement to decide which first
Those with PVD, impotence, DM, COPD without reversibility or interstitial lung disease should have cardioselective BB in the same way as other patients
HF licensed BB to replace other BB after LVSD diagnosed
No upper age limit
If mod – severe symptoms persist prescribe Aldosterone antagonist
If no contraindication, offer supervised exercise based rehab programme – within other rehab programme is OK
Include psychological and educational component
Ongoing management of all patients admitted to hospital should be guided by the opinion of a specialist in HF
Add Hydralazine / nitrate to black patients if remain symptomatic despite BB and ACE I
Consider adding ARB to ACE I / BB if aldo antag not tolerated – NB: specialist decision, monitoring of renal function and K req’d
Consider monitoring of BNP for some eg. Difficult uptitration, admission to hospital
Specialist advice for all:
Initial diagnosis Valve disease HFPEF COPD, CRF, anaemia, PVD, Ur. Freq, gout Angina, AF, other arrhythmia Pregnant/ considering pregnancy
HeartFailure DiagnosticClinic
One stopWithin 2 weeks
BLACKPOOL FYLDE AND WYRE HOSPITALS NHS TRUST
LANCASHIRE CARDIAC CENTRE HEART FAILURE DIAGNOSTIC CLINIC
If the patient does not meet one of the following criteria or has had echocardiogram in the last twelve months – please do not refer to One Stop HFDC
Refer to cardiology via usual channels or to the HF team directly by letter if previously known to them
REFERRAL FORM AND CHECKLIST
Please fax this referral and blood results if required to : Heart Failure Team Fax no: 01253 657845 or referral form initially to [email protected]
HEART FAILURE DIAGNOSTIC CLINIC IS A ONE STOP DIAGNOSTIC CLINIC FOR ANY PATIENT WITH SYMPTOMS/SIGNS SUGGESTIVE OF HEART FAILURE BUT NO PREVIOUS DIAGNOSIS
In addition to echocardiogram and in accordance with NICE guidelines the following will be considered : - The aetiology of heart failure and treatment if required of this condition - The need for additional diagnostic tests eg. stress echo, transoesophageal echo, angiogram - Pharmacological and non pharmacological therapy - The role of device therapy
Diagnosis and management plan will be discussed with a view to increasing patient engagement / compliance A ‘patient held’ record of diagnosis / management will be produced and recorded on a National HF database
This single visit to hospital will better support the subsequent management of the majority of pts in Primary Care
The management and surveillance of the most complex/at risk patients will be undertaken by the hospital HF team in consultation with their General Practitioner and the Community HF team
Patient details
Name :
Address :
Postcode :
Tel.no :
DOB :
NHS no :
Hospital no :
Referring GP
Name :
Address:
Tel. no :
Fax. no:
Referral date: PCT area :
Yes Details
The patient has symptoms suggestive of HF and history of myocardial infarction in the past
The patient has symptoms suggestive of HF and an elevated BNP or BNP is unavailable to your practice we are working with Cardiac Network to improve access
BNP result :
Hospital where assay performed:
APPOINTMENT AT HFDC WILL BE OFFERED WITHIN 2 WEEKS OF CHOOSE AND BOOK REFERRAL, RECEIPT OF COMPLETED REFERRAL FORM and if required (see above) BNP result
All patients should have had blood taken for U&E and FBC – result need not delay referral REFERRAL TO HFDC WILL BE ACCEPTED WITHOUT BLOODS FOR THOSE WITH ALARM FEATURES THIS IS OFFERED ONLY AS AN ALTERNATIVE TO HOSPITAL ADMISSION IF FELT APPROPRIATE
(please tick)
Heart Failure Diagnostic ClinicComprehensive specialist assessment
History/ examination
Echocardiogram
Consideration of need for further investigation – Angiogram, TOE, stress test
Management plan- Lifestyle- Pharmacological- Non pharmacological- Device therapy
Patient education / engagement
• HF referral poster• AQ data
Failures?
•
• Advanced management
Diagnosis
• Routine management
Failures?
•
• Advanced management
Diagnosis
• Routine management
Biventricular Pacemakers
Right AtrialLead
Right VentricularLead
ECG
• P wave• QRS duration
37
38
Biventricular Pacemakers
Right AtrialLead
Right VentricularLead
Left VentricularLead
Biventricular Pacemakers
Biventricular Pacemakers36% reduction
in All Cause Death / CVS death in All Cause Death / CVS death /Hospitalisation/Hospitalisation
CARE – HF: Cleland et al, NEJM, 2005
• Referral for CRT from North Lancs/ Blackpool
Transplant vs. medical Rx
Butler et al. J Am Coll Cardiol, 2004
Cardiopulmonary exercise testing
Survival following cardiac transplant
• 1 year: 85%• 5 years: 73%• 10 years: 58%
www.uktransplant.org.uk
Mechanical support: Ventricular assist devices
Inflow: LV/LA
Outflow: Ao
• Bridge to transplant
• Bridge to recovery
• Destination therapy
Who should receive a VAD as bridge to transplant?
Heart Failure Service - Blackpool
Timely and accurate diagnosis One stop diagnostic clinic
Appropriate/safe/rapid referral pathways Identify high risk patients BNP
Efficient and effective clinical care Treatment optimisation (NICE) Non pharmacological intervention (CRT / ICD, LVAD, Tx)
Communication , Communication, Communication
Community Heart Failure Service
• Uptitration to maximal tolerated medical therapy
• Ongoing surveillance / management of those at high risk of readmission
• Discharge to GP of stable patients
Hospital Discharge
HIGH RISK GROUP
New presentation
to GP
Known diagnosis in
Primary Care
Specialist Consultant led clinic to see all high risk patients ie. :• LBBB on ECG• New AF• Angina• Any ongoing symptoms despite
maximal tolerated medical therapyAll patients should have routine 6 monthly review of:• Symptoms• Medication• ECG: LBBB, AF, HR• UE, FBC
Specialist Consultant led
HF clinicHIGH RISK
GROUPReferral by: • Direct letter• HF helpline
01253 657865
• Advice required• High risk
(see markers below)• Unable to achieve
target dose of medication
Heart Failure One stop
Diagnostic clinic• See referral form• Seen within 2 weeks• Aim discharge with
management plan for majority
• HF helpline
BNP ? Yes
GP follow up• Uptitration to
maximal tolerated medical therapy
• Ongoing surveillance
No
Previous MI?
> threshold
Key
___ Patient numbers to be continually audited and reported by Acute Trust
* Final achievement of target medicaltherapy doses to be periodically auditedand reported by Acute Trust
*
Acute Trust HF nurse also available for advice
/ to facilitate seamless careHF helpline:
01253 303269
In order to reduce risk of readmission all inpatients will be seen during admission or early post discharge by specialist team
Attached
HFDC referral formDischarge report (example)Uptitration advice form
Thank youAny questions?