Heart FailureDr. AliGpst3 Brownhill Surgery

Outline

• Risk factors• Symptoms• Signs• Investigations• Differential Diagnosis• Referral• Treatment

Risk Factors• Smoking• DM• Obesity• Alcohol• High total chol:HDL ratio• LVH on echo• Congenital heart defects• Valvular disorders in elderly• Viral myocarditis• Family history• Drug related

Symptoms

• LVF • SOB, Orthopnoea, PND• Decreased exercise tolerance• Lethargy• Nocturnal cough• Wheeze

• RVF• Swelling of ankles• Abdominal discomfort due to liver distension • Nausea and Anorexia• Fatigue and Wasting• Increased weight

NYHA

Class Patient SymptomsClass I (Mild) No limitation of physical activity. Ordinary physical

activity does not cause undue fatigue, palpitation, or dyspnoea (shortness of breath).

Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnoea.

Class III (Moderate)

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnoea.

Class IV (Severe)

Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Signs• Laterally displaced apex beat• Raised jugular venous pressure• Enlarged liver• Third or fourth heart sound (gallop rhythm)• Tachycardia• Lung crackles (persisting after coughing)• Dependent oedema (legs, sacrum)

Investigations• 12 lead ECG• Natriuretic peptides• CXR• FBC, TFT, E&E, creatinine, eGFR, LFTs, glucose and lipids• Urinalysis, peak flow, spirometry• Echo

Natriuretic Peptides

• Measurement of natriuretic peptide levels helps to determine:• The likelihood of the presence of heart failure.• The need for referral for specialist assessment and confirmation

of the diagnosis by echocardiography.• The urgency of the referral.

Natriuretic Peptides• Two types of natriuretic peptide can be measured: B-type

natriuretic peptide (BNP) and N-terminal pro-BNP (NT-pro-BNP) (Local Lab uses NT-pro-BNP).

• NT-proBNP is the inactive prohormone of BNP and is secreted from the ventricles in response to volume expansion and pressure overload (as occurs in heart failure).

• BNP increases renal excretion of sodium (natriuresis) and water (diuresis) and relaxes vascular smooth muscle, which leads to vasodilation.

Natriuretic Peptides

• Increased levels of BNP or NT-proBNP are present in:• left ventricular hypertrophy, myocardial ischaemia, atrial

fibrillation, pulmonary hypertension, hypoxia, pulmonary embolism, right ventricular strain, chronic obstructive pulmonary disease, liver failure, sepsis, diabetes, and renal impairment, in people older than 70 years of age and in women.

• Levels are lower in people who are obese or are taking drug treatments, such as aldosterone antagonists, angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, beta-blockers, and diuretics.

Referral

• Refer urgently (within 2 weeks) for specialist assessment and echocardiography:• People who have had a previous myocardial infarction (MI).• People without a history of MI who have high levels of natriuretic

peptide — N-terminal pro-B-type natriuretic peptide (NT-proBNP) level above 2000 pg/mL (236 pmol/L).

• People with severe symptoms (if admission is not indicated).• Women who are pregnant.

Referral

• Refer within 6 weeks:• People without a history of MI who have a NT-proBNP level

between 400–2000 pg/mL (47–236 pmol/L).• If natriuretic peptide levels are normal (NT-proBNP less than

400 pg/mL [47 pmol/L]), a diagnosis of heart failure is unlikely. However, referral may still be needed if:• Clinical suspicion of heart failure persists and the person is obese

or taking drugs which lower natriuretic peptide levels (diuretics, angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, beta-blockers, or aldosterone antagonists).

• Another condition is suspected, which requires referral to a specialist.

Differential dx

• Obesity• Respiratory disease• Venous insufficiency in legs• Drug induced (CCB,NSAIDs)• Hypoalbuminaemia• Anxiety• Anaemia• Thyroid disease

Management

Non-drug Mx:• 1. Educate• 2. Discuss ways to make life easier• 3. Diet• 4. Lifestyle measures• 5. Restrict fluid intake• 6. Vaccination• 7. Asses for depression

Management

While patient is awaiting referral:- Drug MX:

Improve Survival• 1. ACE-I /ARB• 2. beta blockers.

How should I manage the person while they are waiting to see a specialist?

• If possible, stop any drugs that may affect the person's heart failure, such as nonsteroidal anti-inflammatory drugs (including those bought over the counter) or calcium-channel blockers.

• If symptoms are sufficiently severe to warrant treatment (but not admission), start a loop diuretic:• Furosemide 20 mg/day to 40 mg/day.• Bumetanide 0.5 mg/day to 1.0 mg/day.• Torasemide 5 mg/day to 10 mg/day.

• Seek specialist advise for pregnant women before initiating any drug treatments.

Complications

• Arrythmias• Stroke• DVT/PE• Malabsorption• Hepatic congestion• Muscle wasting

Angela Graves MSc BSc RN

Heart Failure Nurse Manager/Nurse PractitionerEast Lancashire Heart Failure Nursing ServiceEast Lancashire Hospitals NHS Trust

The impact of heart failure• The National Heart Failure Audit Report (2010) suggests

that heart failure affects one in every hundred here in the UK with this figure rising steeply for those over 75 years to 7%. • Cost to the National Health Service of heart failure is

approximately £625 million, predominantly due to emergency admissions. • NICE (2010) argue that with appropriate diagnosis,

treatment and management morbidity and mortality can be greatly improved.

Prognosis

• Prognosis is poor on the whole, with approximately 50% of people with heart failure dying within four years of diagnosis. Within a year of admission to hospital 32% of patients will die• The mortality rate in the UK appears to be improving. A

UK study found that the six-month mortality rate for people with heart failure had improved from 26% in 1995 to 14% in 2005.• The prognosis for people with heart failure and

preserved left ventricular ejection fraction is a little better than the prognosis for people with heart failure and reduced ejection fraction.

ELHT Heart Failure Nursing Service- What we offer• The Link from Primary to Secondary Care• Review of patient as in patient• Community Clinics• Optimisation of medication• On going management and support• Limited home visiting service• Patients in end stage heart failure

Supportive Services• Heart Failure Nursing Service• Cardiac Rehabilitation Teams• Community Matron/District Nursing • Palliative Care Teams- Hospice services,

Case Study 1

• 35 year old Mr Y attends for review; he first consulted you with flu symptoms approximately 8 weeks ago. He says his symptoms are getting worse; his exercise capacity has been markedly reduced, is orthopneic, and is complaining of weight gain particularly in relation to his abdomen. You order routine bloods and find deranged LFTs, what are your next steps in this management of this patient?

Answer - Case Study 1

• Full bloods U/Es, egfr, LFTs, FBC, Thyroid function, Pro BNP, ESR, CRP• ECG• ECHO• Cardiology Review does he require hospital

admission• CXR• Support network Pumping Marvellous

Case Study 2

• Mrs V aged 85 yrs, is reviewed at home, which is a home for the elderly, she has a history of IHD and recent ECHO you ordered has shown an LVEF of 35%. She experiences no chest pain, but has increasing shortness of breath, mild peripheral oedema, and is currently taking statin, aspirin, Atenolol 25mg, and Ramipril 1.25mg. What medication would you initiate and referrals make?

Answer – Case Study 2

• Managed by the practice• Review of medication, switch to appropriate Beta

Blocker• Up to date bloods look to titrate ACE• Introduction of loop diuretic• Education to staff in the home- what to look out

for• PPC what does Mrs V want