Jen & Amit
With help from City heart failure CNS team
The last battleground of
heart disease!
∗Congenital / valvular disease - corrected by surgeons
∗Incidence of valvular disease - reduced by
immunisation
∗Endocarditis/ myocarditis - treated and prevented by
use antibiotics
∗HTN and high cholesterol - drug therapy
NICE 2010
Definition Chronic HF
∗Heart failure is a complex clinical syndrome of symptoms and
signs that suggest impairment of the heart as a pump supporting physiological circulation
∗Caused by structural / functional abnormality heart
∗Initially HF concentrated on pts with reduction systolic function ∗Over last decade more evident almost half of the patients with
HF syndrome do not have LVSD
∗
Class I - Asymptomatic
∗
Class II –
SOB/ fatigue with normalactivity
∗
Class III - SOB/ fatigue with < ordinary
activity
∗
Class IV – SOB/ fatigue at rest – end stage
∗900,000 people in the UK with HF
∗HF LVSD ↑ improved survival IHD & effective treatment HF
∗HFPEF ↑ due to increase in survival HTN DM AF ↑
obesity
NICE 2010
Incidence and
∗6 month mortality rate ↓ from 26 % in 1995 to 14
% 2005
∗Inpatient mortality ↓ 15 % 2005 to 12% 2009
∗Still significant mortality risk 5 year survival 58%
compared to 93% in the age –sex matched general population
∗HF still has a poor prognosis 30 -40 % of pts. die within 1
year
∗ After 1st year mortality is less than 10% per year
NICE 2010
Mortality over last
∗HF accounts for 2% inpatient bed and 5 % acute
admissions.
∗Over next 25 years predicted to rise by 50 % largely due to
ageing population / improved survival HF / IHD
∗Accounts 2% NHS budget 70 % due to hospitalisation.
∗Length of stay 7-8 days. 25% readmitted within 3 months
GP numbers
∗
30 patients on list with HF
∗
New diagnosis of 10 per year
∗
2-3 visits to the GP per year
∗
1/3 have severe and prolonged
Seasonal Variations
∗
Increased deaths over the winter months
more prevalent over 75’s
∗
↑
9000 deaths CVD
∗
Impact seasonal flu with chronic conditions
∗ 75% Coronary artery disease –Iscahemia/ MI/ HTN
∗ Valvular & congenital heart disease
∗ Arrhythmias
∗ Diabetes mellitus - consider HF preserved systolic function
∗ Alcohol & Drugs – Cardiac depressants Verapermil, Chemotherapy doxorubicin
∗ Pericardial disease –Constrictive pericarditis pericardial effusions
∗ High output failure – Anaemia Thyrotoxicosis
∗ Pulmonary Disease – Right sided HF Pulmonary hypertension
∗ Heart Failure Preserved ejection fraction - HFPEF ∗ cardiomyopathy
Cardiomyopathy
∗Normal
∗EF >60% ∗Hypokinesia
∗EF <40%
∗Akinetic
∗Aneurysm ∗∗DysynchronyDyskinesia ∗Aysynchrony
I feel old Broken
sleep
Frightened of pain
Tablets causing problems
Depressed Feeling
unwell
Can’t just get my head round
it all
Reliant on other people
Can’t drive
Not really in control
Can’t talk to family/ don’t want to burden
them Breathlessness
Spending too much time at hospitals
Concerns of patients & careers
Taking a History from Heart Failure
Patient
∗Presenting symptoms
∗Chest Pain - nature character
∗Dyspnoea - exertion/ rest/ sleeping ∗Syncope - collateral history
∗Palpitations - high % HF patients have arrhythmias ∗Cough - associated with co morbidity or medication ∗Oedema - 3kg can be in tissue before see oedema ∗Fatigue - acceptance of slowing down
∗Mood
∗Cardiac and medical history
∗SoB
∗Persistent cough
∗Nausea
∗Poor appetite
∗Weight gain ∗Bloated
∗Thirsty
∗Swollen limbs
Fatigue
Lack of mobility
Loss Independence Inability to sleep Reduced social activity
Poor memory Low in mood
Clinical assessment
∗Respiration / Breathing
∗ Have a conversation/
accessory muscles
∗ Crepitations ∗ Effusions ∗ Sats on air
∗Cardiac
∗ BP sitting & standing ∗ Signs overload
∗ HR - check apex
∗ Additional heart sounds
∗ Skin
∗ Temperature and colour limbs ∗ Cap refill
∗ Oedema
∗ Broken areas ∗ Muscle tone
∗ Nutrition
∗ Cachexia - checking LFT Albumin
∗ ACE inhibitors – lead to a fall in angiotensin II and
aldosterone
∗ Reversal of effects of vasoconstriction and sodium
retention
∗ Increases cardiac output
∗ Improved tissue perfusion
∗ Complex effects on tissue structure sensory nerve function,
help prevent poor structural remodelling .
∗ Wealth of evidence that ACE inhibitors improve symptoms,
morbidity and mortality in patients with systolic dysfunction
∗
Symptomatic hypotension
∗
headache dizziness fatigue increase risk
falls
∗
ACE inhibitors - dry cough
∗
Renal impairment - Hyperkalaemia
∗
Rash associated pruritus and urticaria
∗
Sinusitis rhinitis sore throat
∗
Angio-oedema particularly Afro-Caribbean
∗Blockade of the direct toxic effects of catecholamines
∗Reduction of systemic vascular resistance (short term BB increase
SVR)
∗Anti - arrhythmic action (incidence sudden cardiac death NYHA II)
∗Reduction in renin secretion
∗Prolonged diastolic filling permitting increased effective
myocardial blood flow
∗Reduced myocardial ischemia
∗Slowing of the heart rate, reduction myocardial O2 demand
∗Evidence of systolic dysfunction – accurate diagnosis / aetiology.
∗Patients stable on ACE or AIIB inhibitors at least 2 weeks
∗No previous history of asthma/ wheeze or syncope
∗Caution:
∗ Concomitant medication that can reduce rate and increase
refraction AV node - Amiodarone, Digoxin, Amlodopine.
∗ PVD
∗ Insulin dependant diabetics history hypoglycaemia
∗Sexually active – may cause problems with impotence
∗Heart failure with persistent angina
∗HFPEF
∗ very cautious with pulmonary hypertension
∗Contradiction or intolerance to ACE or AIIB
∗Persistent arrhythmias
∗Generalised tachycardia
∗Persistent hypertension
Consideration for beta blockers
when not entirely evidence
Beta-Blocker in the
∗Fatigue
∗Low in mood
∗Abdominal upset/ nausea
∗Bradycardia - Brady arrhythmias due to AV block ∗Symptomatic hypotension
∗↓B/P ↓renal perfusion ↑Na+ retention ↑Plasma volume
∗Feeling cold - intermittant claudication ∗Disturbed sleep
∗Exacerbation Psoriasis ∗Wheeze
∗Changes in glucose tolerance ∗Sexual dysfunction loss libido ED
Seek specialist advice and consider adding one of the following if pt remains symptomatic despite optimal therapy with an ACE
inhibitor & b-blocker:
• Aldosterone antagonist esp NYHA class III–IV or MI in past month
• ARB licensed esp NYHA class II-III
• Hydralazine in combination with nitrate esp in Afro-Carribeans with NYHA class III-IV
∗RALES study highlighted the possibility that inhibition of the action of
aldosterone may have an impact beyond that expected from further natriuresis and improved electrolyte balance.
∗Addition of Spironolactone to ACE reduced incidence of death by 35% in patients with grade III IV heart failure.
∗Dosage of Spironolactone was small to reduce the incidence of hyperkalaemia
∗ Regular follow up renal function
∗Eplerenone* post MI with clinical heart failure – for pts intolerant to
Spironolactone
∗22% CRF - Creatinine over 230
∗8 % K > 6.0 mmols Reduce alternative days rather
than stopping
∗8% Gastric upset chronic diarrhoea/ gynaecomastia ∗4% Poor compliance
∗Labour intensive - little support in community for
vene-puncture
∗Symptomatic relief - reduction preload.
∗No evidence loop and thiazide diuretics offer any prognostic benefit
∗Loop diuretics
∗ Powerful action with rapid onset 5 min IV, 30 min orally lasting up to 4-6
hours.
∗Thiazides
∗ Less effect with reduced eGFR – more common in elderly patients ∗ Close monitoring risk hyponatraemia / hypokalaemia
∗ Useful in pts with persistent HTN ∗ Action 1-2 hours last up to 24 hours.
Diuretic use in systolic dysfunction
Diuretic therapy
∗Dose depending upon renal
function
∗Difficulty with diuretics ∗ Poor absorption
∗ Over diuresis ∗ Poor mobility ∗ Incontinence
∗Dignity commode in living room
∗Consider fluid/ salt intake ∗Monitor weight
∗Lowest dose possible to achieve
stable weight avoid dehydrated patient
Who should get which device
∗Titrate all patients to maximum tolerated evidence based
medical therapy
∗Patients with persistent NYHA III –IV symptoms EF <35%
and QRS >120ms with echo dyssynchrony but SR
considered for CRT
∗Those patients with above and conventional indications for ICD
documented ventricular arrhythmias CRTD
∗Those patients with EF <30% after myocardial infarction and
∗Max 2L/ day – where at least moderate overload and
congestion
∗Severely overloaded - 1.5L/day, tighter if hyponatraemia
∗Avoid causing distress – will have a natural thirst
∗Avoid dehydrating drinks ie caffeine, fizzy drinks
∗Advise cold drinks, small ice lollies, flavoured ice cubes, if not
diabetic a boiled sweet, extra soft fruit ie pear
∗Size of the cup - spread drinks
∗In acute heart failure rest can reduce symptoms and help
relieve oedema
∗ Improves renal blood flow and response to natriuretic response to
diuretics
∗ ↓ sympathetic and renin angiotensin systems
∗Little evidence that rest is any benefit in stable chronic
heart failure, rather numerous benefits from carefully increasing physical exertion
∗ Skeletal perfusion ∗ Respiratory function
∗Improves autonomic function reversing pathophysiological changes
∗Adequate and appropriate nutritional balance – consider co-morbidities
∗Poor nutrition may contribute to cardiac cachexia- high risk advanced heart failure - metabolic rate increased up to 20%
∗Poor appetite common
∗ Drug induced – Digoxin, amiodarone, aspirin, statins ∗ Hepatic congestion
∗ Co-morbidities – CRF
∗Specific advise on Salt 6g /Sodium 2g intake per day
Dietary
If obese weight loss should be encouraged ↑ BMI ↑ cardiac
∗Encourage all smokers to give up
∗Smoking has adverse haemodynamic effect ↓cardiac output
∗ Increase heart rate and blood pressure ↑ myocardial O2 demand
∗ ↑ carboxyhaemoglobin risk of emboli
∗Restrict alcohol and with related cardiomyopathy abstain completely
∗Alcohol has myocardial depressant properties – in excess predisposes to arrhythmias especially atrial fibrillation
∗Volume may also lead to alterations in fluid balance
∗Knowing stable weight
∗ same time day each day then couple of times a week
∗Watch for increased oedema
∗ Awareness what can cause increase fluid volume ↑Sodium / NSAID
∗Self adjusting of diuretics
∗ Pre set guidance to adjust by one dose loop diuretic for set day
∗Knowing when to cut back
∗ D&V/ hot weather
∗ Travelling if poor access to toilet facilities
∗Knowing who to contact
∗ How often need U&Es
∗ Contact numbers for exacerbation symptoms
Focus CNS HF Role
∗ Post Discharge Visit
∗ Education chronic disease life style and ADL’s
∗ Monitoring Complex Patients
∗ Titration Medication
∗ Concordance issues
∗ Review stable patients step down from service
∗ On going support poorly patients
∗ Palliative and terminal care .
HF CNS SOS review
∗In 1 month 16 SOS calls to HFN
∗9 would have called GP
∗7 would have called ambulance
∗All were discussed at monthly HF CNS team meeting
Initial diagnosis
Management of severe heart failure (NYHA class IV),
Not responding to treatment
Can no longer be managed at home
Planning a pregnancy or are pregnant
Heart failure due to valve disease
Consideration of devicesNICE 2010
Long term monitoring
patient
∗Despite widespread use of ACE
inhibitors and beta-blockers, both
shown to prolong survival and reduce mortality, optimal management
remains poor.
∗Randomised studies examining the
∗Different agendas - keeping consultations on track and remaining holistic
∗Adherence to medication – 0ver lifespan
∗Inconsistent advice – HF usually secondary already received advice
∗Recognising own limitations - working with MDT
∗Lack of resources, access to investigations
∗Lack respite facilities – limited resources palliative care
Cancer Heart failure
∗Phase 1 Symptom onset,
diagnosis and initiation of
medical treatment. Often started by hospital admission
medication and education
∗Phase 2 Under the care of
community teams. Ongoing support and education for
patents and carers promote autonomy, self care, adherence, when to call for help and reduce inappropriate admissions.
∗ Phase 3 Periods of instability with
recurrence of symptoms due to deterioration in heart function
Rebalancing of treatment, implantable cardiac devices.
∗ Phase 4 Increasing symptoms &
declining physical capacity, despite optimal therapy.
∗ Phase 5 Multi-organ failure
Supportive and palliative care needs.
Trajectory of death
indications
∗Signs organ failure
∗ Worsening renal function
∗ Dropping Sodium and potassium ∗ Liver function congested pattern
∗Falling Haemoglobin – associated with CRF ∗ Gallop rhythm
∗ Persistent tachycardia -
∗ Increased activation and firing ICD if implanted
∗Unexplained weight loss
∗Worsening of co-morbidities
Supportive Care
∗ Identify & Treat Aetiology ∗ Additional investigations ∗ Active Treatment
∗ Devices
∗ Motivation - self belief ∗ Self manage, target risk
factors
∗ Encourage coping ∗ Enhance Hope
∗
Palliative Care
∗QoL
∗Symptom management ∗Minimise medication ∗Anticipatory meds ∗Preparing for end of
natural life
∗Consider inactivate ICD ∗Consider place of death ∗Reduce fears, comfort
Palliative Care and Heart Failure
∗ Decision to discontinue active treatment and adopt palliative
approach is rarely encountered
∗ Lack of acknowledgement to change the emphasis of treatment to
symptom management
∗ Identification of the point of transition to a terminal phase is very
difficult, may have survived previous life threatening episode
∗ High prevalence of unexpected death, impact on carer and
∗Heart failure is a common disease and its on the increase
∗There are growing number of evidence based therapies
that can improve both prognosis and reduce morbidity.
∗Life style skills offered to patients can improve stability
∗The diagnosis is often missed and the patients are often
under treated
∗Provision for palliative care is under funded considering
the mortality and malignant nature of the disease
∗Lack dedicated workforce - aim to raise awareness to
wider MDT
