Heart Failure. Ron Leslie - PowerPoint Presentation

Slide1

Heart Failure.

Ron Leslie

19/07/2017

Aims.

Heart failure definition and

epidemiology

Heart failure ‘types’ and treatment

Case studies

Definition.

PHYSIOLOGICAL – inability of the heart to pump sufficient oxygenated blood to the metabolizing tissues despite an adequate filling pressure.

CLINICAL – syndrome consisting of symptoms caused by cardiac dysfunction.

Gardner et al (2007)

Epidemiology.

The incidence of heart failure is approximately 57.9 per 100,000 with a prevalence of approximately 1%. (Townsend et al. 2012).

Heart failure hospitalisations account for up to 70% of heart failure expenditure and 2% of all NHS bed-days.(NICE 2010)

Once patients suffer their first HF admission to hospital, 40.2% of HF patients die within 12 months, based on data from all heart failure patients across England on QOF HF registers.(HSCIC 2015)

5-year survival

rates

for heart failure are worse than for common cancers such as breast and prostate.(

Askoxylakis

et al. 2010) Patients on GP heart failure registers, representing prevalent cases of heart failure, have a 5-year survival rate of 58% compared with 93% in the age- and sex-matched general population.(NICE 2010).

Diagnosis.

History

Clinical Assessment

Natriuretic

Peptides;

Two most common:

B-type

Natriuretic

Peptide (BNP)

N-terminal pro B-type

Natriuretic

Peptide (NT-

proBNP

)

Exclusion threshold at presentation (ESC 2012):

BNP: Acute 100pg/ml, non acute 35pg/ml

NT-

proBNP

: Acute 300pg/ml, non acute 125pg/ml

Echocardiogram

Aetiology of Heart Failure.

Ischemic Heart Disease

Hypertension

Valve disease

Arrhythmias

Cardiomyopathy

Congenital Heart Disease

Iatrogenic

Metabolic

McDonagh et al (2011)

Clinical Features.

Clinical features

Sensitivity (%)

Specificity (%)

Breathlessness

66

52

Orthopnoea

21

81

PND

33

76

History of oedema

23

80Tachycardia799Pulmonary crackles1391Oedema on examination1093Third heart sound3195Raised JVP1097

McDonagh et al (2011)

Left Ventricular Systolic Dysfunction.

Signs and symptoms of heart failure +;

Reduced ejection fraction (Steed et al 2011);

Normal ≥55%

Mild LVSD 45-54%

Moderate LVSD 35-44%

Severe LVSD ≤35%

Significant volume of empirical evidence available on its management

Pharmacological

Intervention / Devices

NICE Chronic Heart Failure Guidelines (2010), Nice Quality Standard

+ QOF indicators available

to standardise practice

Pharmacological management.

Multitude of clinical trials and guidelines which supporting the use of medications in the management of heart failure;

First line treatment:

ACE Inhibitor / Angiotensin receptor blocker

Beta Blocker

Second line treatment:

Mineralocorticoid receptor

antagonist

Entresto

(

Sacubitril

/Valsartan

)

If symptoms persist despite above interventions:

Ivabradine

DigoxinHydralazine / Nitrate

Neuro-hormonal Activation.

Renin-Angiotensin-Aldosterone System.

Sympathetic Nervous System Activation.

Diastolic Dysfunction.

Left ventricular diastolic dysfunction is thought to be the underlying pathophysiological abnormality in patients with HF-PEF (ESC 2012)

No single echocardiographic parameter is sufficiently accurate and reproducible to be used in isolation to make a diagnosis (ESC 2012)

E/A ratio commonly commented on in echocardiogram reports where diastolic dysfunction is reported

NICE (2010) recommends to treat co-morbid / contributory conditions in line with published NICE guidance.

Right Heart Failure.

Usually occurs as a consequence of respiratory disorders / pathophysiology

Cor

pulmonale

Can be a caused by primary cardiovascular disease e.g. mitral valve disease, right ventricular infarction

Typically systemic congestion is main physical manifestation and cause of symptoms

Specialist regional centres exist for the management of pulmonary hypertension

Fluid Management.

Measurements of fluid status:

Input/output chart

Daily weights

CVP

Fluid Restriction:

Education

Documentation / communication

Diuretic therapy:

IV

vs

Oral

Multiple agent choices

Kidney function

Haemodynamic Alterations.

Patients with cardiac conditions may experience:

High /

l

ow blood pressure

Fast / slow heart rates

Questions to consider:

What are the patients normal parameters?

Are they compromised by abnormal findings?

What is their NEWS score, may this be adjusted for long term condition?

Most importantly remember:

Documentation

Communication

Planning

Case Study 1.

29 year old male

MHX: Dilated cardiomyopathy (alcoholic), Chronic kidney disease, CRT-D.

Echo: LVEF 20%, dilated left ventricle and atrium, trivial valve disease.

Recent hospital admission, attending surgery for medication review:

SOB – NYHA III

Fatigue

Orthopnea

PND

Case Study 2.

66 year old male.

MHX: Hypertension, Prostate Cancer,

Anaemia,

Type II Diabetes

Echo: LVEF 57%, mild concentric left ventricular hypertrophy

Seen in surgery due to increasing symptoms, poor blood pressure control:

Symptoms;

SOB – NYHA III

Orthopnea

Palpitations

BNP 4000pg/ml

Case Study 3.

82 year old female

MHX: COPD, Pulmonary Hypertension, Rheumatoid Arthritis, Chronic Kidney Disease

Echo:

LVEF

58

%, Mild mitral regurgitation, moderate tricuspid regurgitation, RVSP 54mm/Hg, moderate/ severe dilated right atrium and ventricle

Review due to abnormal kidney function (stage 3BCKD):

SOB – NYHA IV

Fatigue

Orthopnea

Any Questions?

References / Resources.

AskoxylakisEmail

V,

Thieke

C,

Pleger

S, Most

P,Tanner

J,

Lindel

K,

Katus

H, Debus J,

Bischof

M 2010 Long-term survival of cancer patients compared to heart failure and stroke: A systematic review 10:105 BMC CancerGardner RS, McDonagh TA, Walker NL 2007 Oxford Specialist Handbooks in Cardiology – Heart Failure Oxford: Oxford University Press

McDonagh

TA, RS Gardner, AL Clark and H

Dargie

2011

Oxford Textbook of Heart Failure

Oxford: Oxford University Press

McMurray

, JJ, S

Adampoulos

, SD Anker et al ESC Committee for Practice Guidelines 2012 ESC guidelines for the diagnosis and treatment of chronic heart failure

European Heart Journal

33 (14)

1787-1847

National Institute for Health and Clinical Excellence 2010

Chronic heart failure management:

London

Steed R, Wharton G, Allen J, Chambers J, Graham J, Jones R,

Rana

B,

Masani

N 2011

Echocardiography Guidelines for Chamber Quantification

British Heart Foundation: London

Townsend N,

Wickramasinghe

K,

Bhatnagar

P,

Smolina

K,

Nichols M, Leal J,

Luengo

-Fernandez R, Rayner M

2012

Coronary heart disease statistics 2012 edition

. British Heart Foundation: London.