Heart Failure Update Friday 13 January - PowerPoint Presentation

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Heart Failure Update Friday 13 JanuaryDebbie RootsCardiorespiratory Nurse ConsultantRosy ScottCommunity Heart Failure Lead NurseSlide2

W

ho are we and what can we do?

Debbie RootsCardiorespiratory Nurse Consultantdebbie.roots@nhs.netSlide3

Integrated Care pathways

Cardio-respiratory Rehabilitation

Domiciliary VisitsIn-Reach and specialist bundles of care

Support, education and advice

Admission Avoidance

Complex Case Management

Early Supported Discharge

Palliative Care

Primary Care HF Clinics

Oxygen

PsychologySlide4

ACERS ACERS team has been in existence since 2009Initially it was for COPD patientsAim was to reduce admissions and support patients to self manage.Hospital at home response serviceEarly supported dischargeSlide5

“To provide a comprehensive, integrated, responsive community-focused COPD service, for acute exacerbations and ongoing chronic disease management, which meets the diverse needs of City & Hackney patients in a sustainable and timely manner”

Old Service Philosophy???Slide6

Primary Care SupportCommunity Based Rapid ResponseEmergency Department InterventionEarly Supported DischargeCommunity ClinicsEducation End of Life Pathway

Service ModelSlide7

Patient

GP

Practice nurse

Clinic

Medical Wards

Emergency Department

Community

Matron

Other

health professionalsSlide8

ACERSFrom 1st November 2016 we extended the service to incorporate Cardiac rehabilitation and Heart failure services.Now one big happy teamSupport each otherSlide9
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Clinical ResponsibilityACERS have regular contact with Respiratory and cardiac Consultants and SpREasy access to hospital diagnosticsRegular communication with Practice Nurse & GPGP asked for input with co-morbidities problems when appropriateSlide11

BasesRespiratory Medicine Portacabin at the back of Homerton hospital.D Block 2nd floor –St Leonards HospitalSlide12

Outcomes that matter to us allImproved Survival Earlier and Accurate Diagnosis Improved Quality of Life Slower disease progression Reduced exacerbation rate Reduce hospital admission & re-admission ratesHigh Quality End of Life care Patient centred quality careSlide13

How to referFax: 0208 510 7659Telephone-Respiratory: 02085105107 Heart failure: 02076834698Respiratory OHH: 07920 150047Email-referral form toRespiratory- Homertoncopd@nhs.netCardiac-

huh-tr.homertonheartfailure@nhs.net

Referral forms are on the intranetSlide14
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Heart Failure in Primary CareRosy ScottCommunity Heart Failure Lead NurseJanuary 2017Slide17

Heart Failure with Preserved Ejection Fraction (HF-PEF)More recently the syndrome of HF has been recognised in patients with normal or ‘preserved’ EF (HF-PEF)At least 50% of patients (Borlaug, 2011)Prevalence increasing over past 20 years (Oghlakian, 2011)No treatment to date has been shown to offer major prognostic benefit in patients with HF-PEFMany RCTs but few large-scale studiesEvidence base therefore weaker and lack of consensus regarding standard pharmaceutical guidelines to support management of HF-PEFLeads to more variable practice and may contribute to worse outcomes for HF-PEF (Lam, 2014)Slide18

Heart failure with preserved ejection fraction (HFPEF)NICE definition: [HFPEF] is usually associated with impaired left ventricular relaxation, rather than left ventricular contraction, and is characterised by a normal or preserved left ventricular ejection fraction.Slide19
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HF-PEFPatients with HF-PEF tend to be older than those with LVSDMore likely to be femaleHypertensionHigher rate of AFLower rate of CAD30% higher death rate of HF-PEF compared to LVSD may be due to co-morbiditiesDiabetes, hypertension, obesity, OSA, CKD all associated with HF-PEF and may play a part in its pathophysiology and result in higher rate of hospital admissions (Li, 2013).Slide21

The ‘wrong type of heart failure’?Although strong evidence base for ‘standard’ HF medication exists for LVSD only, evidence for the benefits of organised specialist multi-disciplinary care exists for the whole HF population both in hospital and in the communityNICE recommends that all HF patients should be referred after discharge to a specialist HF serviceSlide22

ChallengesNo strong evidence base for treatmentSuffer the same symptoms as LVSD: breathlessness on exertion, reduced exercise tolerance, fatigue, fluid overloadJust as likely to be admitted with symptoms of fluid overloadNot under a cardiologist?More likely to be admitted under other physiciansShould these patients be on the GP HF registers? Slide23

Other conditions that may present with similar symptoms

• Obesity

• Hypoalbuminaemia

• Chest disease – including of lung, diaphragm or chest wall

• Intrinsic renal or hepatic disease

• Venous insufficiency in lower limbs

• Pulmonary embolic disease

• Drug-induced ankle swelling (e.g. dihydropyridine calcium channel blockers)

• Depression and/or anxiety disorders

• Drug-induced fluid retention (e.g. NSAIDs)

• Severe anaemia or thyroid disease

• Angina

• Bilateral renal artery stenosisSlide24

Heart Failure RegistersNot as easy as it sounds!LVSD, mild/mod/severeLVDD, mild/mod/severePreserved (HEFPEF/HEFNEF) Mild long axis dysfunctionPulmonary HypertensionRight sided HFValve diseaseAll on one register, all with different needs, evidence-based medicine and care as per guidelines - NICE, ESC – for LVSD onlyNYHA class can be useful but be aware of SOB due to other causes, differential diagnosesPrevalence of Hypertension in C&H – high rate of HEFPEF,

esp

in Afro-Caribbean community Slide25

National Institute for Clinical Excellence (NICE) (2003) (Updated 2010) Chronic Heart Failure: management of chronic heart failure in adults in primary and secondary care www.nice.org.ukSlide26

What do the guidelines say? (1)ESC (2012): Diuretics control sodium and water retention – relieving breathlessness and oedema (as in HF-REF)Adequate treatment of hypertension and myocardial ischaemia is considered to be importantControl of ventricular rate in patients with AFVerapamil may be useful (unlike in HF-REF) Slide27

What do the guidelines say? (2) NICE 2010Diuretics should be routinely used for the relief of congestive symptoms and fluid retention in patients with heart failure, and titrated (up and down) according to need following the initiation of subsequent heart failure therapies. [2003]The diagnosis and treatment of heart failure with preserved ejection fraction should be made by a specialist, and other conditions that present in a similar way may need to be considered. Patients in whom this diagnosis has been made should usually be treated with a low to medium dose of loop diuretics (for example, less than 80 mg furosemide per day). Patients who do not respond to this treatment will require further specialist advice. [2003]Slide28

Calcium channel blockers in HF-REF1.2.2.19 Amlodipine should be considered for the treatment of comorbid hypertension and/or angina in patients with heart failure, but verapamil, diltiazem should be avoided. [2003](Reduce contractility and stroke volume)Slide29

Calcium Channel Blockers in HF-PEFNon-dihydropyridine calcium-channel blockers (verapamil and diltiazem) are said to improve diastolic function in patients with HF-PEF. Negative chronotropic and inotropic properties may help the ventricle to

relax

As contractility may be normal in diastolic dysfunction these drugs do not seriously impair stroke volumeSmall studies onlySlide30

Case Study Mr NAged 77 yrsAfro-CaribbeanFirst seen in HF clinic at GP practice May 2015Slide31

Medical HistoryHypertensionDiabetes Type 2CKD stage 3Previous PE (2000) DVT (2014) (on Warfarin) GoutGlaucomaDiabetic retinopathySlide32

Medication at first appointmentAllopurinol 300mg odAmitriptyline 50mg nocteAmlodipine 10mg odColecalciferol 400u/Ca carbonate 1.25g x1 bdDoxazocin 4mg bdFurosemide 80mg

bd

Humulin Insulin nocteLactuloseSennaLinagliptin 5mg odLansoprazole 30mg odLosartan 100mg odNebivolol 5mg bdSimvastatin 40mg nocteWarfarin (previous DVT)Dorzolamide 2% eyedrops

x1 tds both eyesBimatoprost 100mcg eye drops x1 noctePred Forte eye drops 1% Slide33

Cardiac history (1)June 201414 day stay – admitted under cardiologist with leg swelling to above knees, shortness of breath, bi-basal cracklesECHO: LV normal cavity size, preserved systolic function, LVEF 55%, Mild LVH. MPS: normal study, no reversible ischaemia, LVEF 62%Treated with IV furosemide, fluid restriction Weight on admission 113kg, weight on d/c 108kgf/u in cardiology OPA and then d/c as stableSlide34

Cardiac History (2) Next presented to A&E 16th April 2015:c/o severe abdominal swelling and swelling to upper thighsAbdomen grossly distended, no obvious shifting dullnessJVP not visibleMild pitting oedema to thighsAbdo Xray – dilated bowelCXR – nil acute, enlarged heart

Diagnosed as constipation (BNO for 3 days) d/c same day with

Movicol. Slide35

MovicolOral powder, macrogol ‘3350’ (polyethylene glycol ‘3350’) 13.125 g, sodium bicarbonate 178.5 mg, sodium chloride 350.7 mg, potassium chloride 46.6 mg/sachet,Amount of potassium chloride varies according to flavour of Movicol® as follows: plain-flavour (sugar-free) = 50.2 mg/sachet; lime and lemon flavour = 46.6 mg/sachet; chocolate flavour = 31.7 mg/sachet. 1 sachet when reconstituted with 125 mL water provides K+ 5.4 mmol/litre

Cautions:

patients with cardiovascular impairment should not take more than 2 sachets in any 1 hour Dose chronic constipation, ADULT and CHILD over 12 years, 1–3 sachets daily in divided doses usually for up to 2 weeks; maintenance, 1–2 sachets dailyFaecal impaction, ADULT and CHILD over 12 years, 4 sachets on first day, then increased in steps of 2 sachets daily to max. 8 sachets daily; total daily dose to be drunk within a 6 hour period. After disimpaction, switch to maintenance laxative therapy if requiredSlide36

Cardiac History (3)3 days later Referred to A&E by DN as legs swollen and so not able to put on compression stockings?DVT ? Worsening CCFNo evidence of DVT, treated with IV Furosemide 40mg , advised to increase oral Furosemide to 80mg bd. Sent home same day.GP to follow up. Slide37

Discussion pointsLong stay under cardiology 2014, aetiology exploredNo referral made to HF nurses at that time2 very short stays in 2015 sent home same day, not admitted/not seen by cardiologistMovicol?Slide38

In the HF clinicBP 142/71, heart rate 76/min regularWeight 113kgPitting oedema to top of thighs, scrotal oedema, chest clear, abdomen distended, no shifting dullness.JVP not raised3 pillows (usual) SOBOE worse over past year, no PND, no SOB at restSlide39

PlanRepeat echo, do ECG, repeat U&Es, LFTs, FBCU&Es: Na 141, K 4.1, Urea 12.4, Creatinine 184, eGFR 38.Prescribed Metolazone 2.5mg twice a week for 1 month onlyRpt U&Es 1 week later (after 2 doses Metolazone):

Na 143, K 4.3, U 16.0, Creatinine 184,

eGFR 38 Advised re salt and fluid intakeSlide40

Follow-upU&Es 1-2 weekly remained stableSeen by PN, DN, lymphoedema team, GPSeen in next HF clinic:Lost 3.6kg! Less SOB, more energetic, scrotal and leg oedema still present but improvingPlan – continue current regimeSeen in next HF clinic:Lost further 2.3 kg (5.9kg

weight loss)

Oedema to just above knees, scrotal oedema resolved.BP 136/68, heart rate 64/min U&Es: Na 138, K 4.4, Urea 11.9, C 165, eGFR 43Stopped Metolazone. Slide41

Echo and ECGRpt echo:Normal LV sizeBorderline LVHNo RWMAPreserved LV function, EF 66%Moderate Diastolic Dysfunction Dilated LAValves normalGood RV functionSlide42

ECGSinus Rhythm RBBBLeft anterior hemiblockNormal PR intervalShould he still be on a beta blocker? Slide43

Follow-up Regular follow ups with HF nurse and GPTotal weight loss: 7.5kg (without admission…)Seen next in January 2016: Weight creeping up, had gained 1.3kg feeling more SOB, more uncomfortable, felt he was ’slowing down again’. BP 154/75U&Es: Na 138, K 5.1, Urea 10.4, C 170, eGFR 34Added Spironolactone 25mg od Slide44

Follow-upReview in HF clinic Jan 2017 Rpt U&Es: Na 138, K 4.8, Urea 12.6, C 207, eGFR 33. Lost 2kg, feeling better. BP 134/64Right breast tender, sore, enlargedGP had sent for breast screening in November –NADDiagnosis?Slide45

SpironolactoneRALES trial (Spironolactone) showed 10% HF patients developed gynaecomastiaEPHESUS trial (Epleronone) 0.5% HF patients Plan: switch to Epleronone, same dose 25mg odRe-check U&EsHow often should you check U&Es with a patient on Spironolactone/Epleronone

?Slide46

IvabradineIf channel blockerOriginally licenced for treatment of anginaSlows impulses from Sinus Node to lower heart rate without lowering BP Useful add on for beta blocker or to use if beta blockers not tolerated/contraindicatedStudies: SHIFT, BEAUTIFULDose: 5mg bd

Criteria:

LVSD, EF ≤HR ≥ 75bpmSINUS RHYTHMSlide47

IVABRADINE SIDE EFFECTS•Eyesight problems which include blurred vision and having brief moments of increased brightness, most often caused by sudden changes in light intensity.•Bradycardia•Headache•DizzinessPalpitations•Nausea•ConstipationSlide48

Sacubitral-ValsartanAngiotensin receptor-neprilysin inhibitor (ARNI)Sacubitral - inhibits action of enzyme neprilysinNeprilysin - Valsartan – ARBStudy: PARADIGM-HF, compared Sacubitral-Valsartan with Enalapril:Improved symptoms and reduced cardiac and all-cause mortality, reduced risk of hospitalisation.

In patients with LVSD/HF-REF

To be initiated by cardiologist/under cardiologist supervision as need to stop ACEi first ‘flushing out’ period required before starting Sacubitral-ValsartanSlide49

Cardiac injury

Pump failure (

LVSD

) Cardiac output

Neurohormonal

Activation

Renin Angiotensin Aldosterone System

(RAAS)

Sympathetic Hormone System -

(SNS)

Adrenaline and noradrenaline

Vasoconstriction

Na+ and H2O

retention

HR Slide50

Neuro-hormonal pathways in pathophysiology of HF Following cardiac injury the RAAS and the SNC act together to maintain perfusion of vital organs.Without treatment, over activity of these systems result in:Continuing vasoconstrictionSodium and water retentionCardiac hypertrophyVascular wall fibrosis Slide51

NeprilysinAdverse effects of RAAS and SNS are counteracted by the naturetic peptide system (NPS)Naturetic peptides are degraded by the enzyme neprilysin So a neprilysin inhibitor + ARB enhances the protective effects of the NPS while blocking the RAASSlide52

Sacubitral-valsartanNICE:Symptomatic Chronic Heart Failure HF-REF with NYHA class II – IV and EF ≤ 35%Already taking stable dose of ACEi or ARBESC (May 2016):Sacubitral-Valsartan should replace ACEi in ambulatory patients with HF-REF despite optimal ACEi/BB/MRAUnder cardiology supervision as ‘washout’ period of 36 hrs after stopping ACE.

eGFR

≤30 start lower dose and up-titrate.Do not use in severe hepatic impairmentWatch for hypotension, hyperkalaemia.Twice daily dose so concordance may be an issue.Slide53

HF/Pulmonary rehabilitationRestarted2 sites – Clissold Leisure Centre and Brittania Leisure CentreOnce a week for 10 weeks alongside pulmonary rehab patientsRefer to HFNS using standard referral form and tick rehab boxWill be screened by us so patient may not be accepted if does not fit criteriaSlide54

Inclusion CriteriaUnder care of City and Hackney GPConfirmed HF diagnosis with echo resultsNYHA class II/III, limited by breathlessness or fatigue

Under care of HF nurse specialist

Stable condition for 4 weeksMedical treatment optimisedAble and willing to attend groupSlide55

Exclusion CriteriaUnstable heart failure eg. Symptomatic & >2kg weight increase in 2-3 days Progressively worse execise tolerance & dyspnoea over 2-3 days

Unstable angina: recent MI (<6 weeks)

Unstable diabetesUncontrolled hypertension (180/110) or systolic <80Uncontrolled arrhythmiasAcute Left Ventricular failureResting HR >100-110 or <40 or significant change from usual HRNewly diagnosed AFImplantable cardiac defibrillator shock in the last 4 weeksSignificant change in or failure to comply with medicationsAll other acknowledged cardio-vascular exercise contraindications eg. Significant or exercise induced arrhythmia, systemic illness, recent myocarditisCardiac intervention planned in the near futureSlide56

HF ClinicsGives GPs ‘ownership’ of their patients with CHFSupporting GPs to manage complex HF patients within GP practice without needing to refer to secondary care in many casesPromotes mutually rewarding and trusting GP/HFN relationshipsPatients like the service30 minute session per patient gives time the condition deserves, allows time to explore and manage: Medical, social, pharmacological, educational, family/carer supportAll HF registers now ‘tidied up’ all patients have diagnosis confirmed, pts without HF off the register, case finding has added to some HF registersAlso thanks to open access echo service, 24 hr Holter etc

, advice line – referrals to cardiology are appropriateSlide57

QuestionsSlide58

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