Excelling in heart failure care

Dr Alex Simms, Consultant Cardiologist

Outline

▪ What is heart failure

▪ Why is it important

▪ Diagnosis

▪ Care in Primary Care

▪ Modern management

Definition of heart failure

A clinical syndrome with typical symptoms/signs caused by structural and/or functional cardiac

abnormality, resulting in a reduced cardiac output or elevated intracardiac pressures at

rest/stress

ESC HF guidelines. EHJ 2016; 37:2129

Heart Failure Syndrome

HF reduced EF HF mildly reduced EF HF preserved EF

EF≤40% EF>40-49%+ elevated BNP/NTproBNP

+ LVH, LAE or diastolic dysfunction

EF>50%+ elevated BNP/NTproBNP

+ LVH, LAE or diastolic dysfunction

Limited evidence base for treatmentExclude other causes

These terms define treatment

in guidelines

LVSD Non-LVSD

Why is heart failure important?

2%

Up to 15,000 in LEEDS

(and increasing)Poor QoL

1-year mortality 30% 5-year mortality 45%

HF admission

Post HF diagnosis

1-year mortality 19% 5-year mortality 49%

Why is heart failure important?

Conrad N et al. Lancet 2018;391:572–580

Not all recognised

Chronic non-curable

Heart Failure Diagnosis in Primary Care

Suspicion of heart failure syndrome

High index of suspicion

Treat symptomsOptimise Check NT pro BNP

(+U&Es, FBC, LFTs, TFTs, Urine PCR, HbA1c, CXR,

ECG)

NT pro BNP<400ng/L NT pro BNP>400ng/L

Not heart failure syndrome

Do not referSeek alternative

Refer Cardiology

Heart Failure Chronic Disease Review

Can we do better?

Heart Failure Chronic Disease Review

Modern Management of Heart Failure

Improve QoL

Improve Prognosis

Avoid HF decompensation

and/or hospitalisations

Education Medical therapy

Device therapy

Advanced heart failure

care

End stage disease

(Palliative care)Foundation of heart

failure care Specialist Care

Modern Management of Heart FailureHF syndrome confirmed

Treat symptoms (congestion/fluid

overload) with LOOP DIURETICS

LVSD Non-LVSDStrong evidence

base for treatment

Diuretics

Discretionary

Optimise other co-morbidity

Optimise weeks 4-8

Initiate all in weeks 0-4

Modern Management of Heart FailureFor HF from LVEF<40%

ACEiRamipril 2.5mg OD

Beta-blockerBisoprolol 2.5mg OD

ARNISacubitril Valsartan 100mg BD

or MRASpironolactone 25mg OD

SGLT2iDapagliflozin 10mg OD

Ramipril 5mg OD

Bisoprolol 5mg OD

Sacubitril Valsartan 200mg BD

Spironolactone 50mg OD

If NYHA I (if not switch to ARNI)

Ramipril 10mg OD Bisoprolol 10mg OD

Green: Primary Care can initiate and optimise

AMBER I : Specialist recommendation, can be initiated and optimised in Primary Care

AMBER III**: Specialist initiation and optimisation (**Primary may be asked to initiate to reduce inequality of care)

Modern Management of Heart FailureFor HF from LVEF<40%

Target Doses by end of week 8

Sacubitril Valsartan 200mg BD

Spironolactone 50mg ODRamipril 10mg OD Bisoprolol 10mg OD Dapagliflozin 10mg OD

Green: Primary Care can initiate and optimise

AMBER I : Specialist recommendation, can be initiated and optimised in Primary Care

AMBER III**: Specialist initiation and optimisation (**Primary may be asked to initiate to reduce inequality of care)

Device Therapy

ICD if LVEF<35% on OMT

CRT consider if QRS duration >130ms

or

Outline

▪ What is heart failure

▪ Why is it important

▪ Diagnosis

▪ Care in Primary Care

▪ Modern management

Heart Failure Chronic Disease ReviewEstablished diagnosis of Heart FailureDefine phenotype: LVSD or non-LVSD

Optimise patient’s HF (refer to pathways)

• Education & understanding• Diuretics• ACEi/ARNI• Beta-blocker• MRA• SGLT2i• Eligible device therapy• Co-morbidity• Medicines Review

Chronic disease ReviewStable/asymptomatic/NYHA INone of above

Refer for HF Specialist ReviewPersistent symptoms/signs HFDevice eligibilityInitiation of specialist medicationsEnd stage diseaseNot sure what to do

Perform Chronic Disease HF Review every 6-months

HF CCSP available

Assess at every opportunity:

▪ NYHA class, fluid status, symptoms/signs▪ HR, BP, Weight▪ U&Es/FBC (6-monthly)▪ Yearly LFTS, HbA1c & ECG▪ Treatment & if optimised

If decompensating HF consider causes:

▪ Arrhythmia (e.g. AF)▪ Anaemia▪ Concurrent illness (e.g. infection)▪ Medication compliance▪ HF progression (is this end stage disease?)▪ Consider referral to Community or

Secondary Care HF services

Check on HF and/or LVSD register in Primary Care

Education & Support

Lower risk, less complex

Higher risk, more complex

MDT & Virtual Clinic

HF Nurse Specialist Service

Primary Care Practice

Primary Care Clinical Pharmacist

HF Cardiologist

The Leeds Integrated Heart Failure Service Model