Heart Failure: From Failure to Success

Dr. Alison Seed

Consultant Cardiologist

Failures?

• In diagnosis

• In routine management

• In advanced management

₤ To address the personal AND financial burden

Diagnosis...........

Prevalence>45yrs

National (expected)

2.3%

NationalBlackpool PCT (recorded)

1.8%(0.19-5)

1.Pushing the boundaries: Improving services for people with heart failure. HCC(CHAI ) 20072. State of healthcare: Improvements and challenges for services in England and Wales. HCC (CHAI) 20073. Blackpool GP HF register data: Brian Harrop, Blackpool PCT

MORTALITY BENEFIT OF BETA-BLOCKERS AND ACE-INHIBITORS IN CHF TRIALS

0

2

4

6

8

10

12

14

16 SSOLVD (1991) CIBIS II

MERIT-HF (1999)

diureticdigoxin

diuretic digoxin ACE-I

diuretic digoxin ACE-I

diureticdigoxin ACE-Ibeta-blocker

% d

eath

at

1 ye

ar

Routine management..........

Advanced management........

Implant rate / million population / year

USA

average

EU

average

UK

target

UK

average

Lancs. South

Cumbria 2006

ICD 610610 160160 100100 4646 2828

Bi V

PPM275275 7575 140140 5656 5858

Personal and financial burden...

Poor prognosis– 10-50% mortality per year

Poor quality of life– Poor exercise tolerance– >30% depressive illness

Frequent hospital admission– 5% of acute medical admissions– 40% death /readmission in one year

Long length of stay– > 8 days– 2% of in patient bed days

2% total annual NHS expenditure

CostCost

Hospital admission length of stay

Healthcare Commission 2007

• HF diagnostic services poor − Diagnosis difficult because symptoms non specific and physical

signs not obvious− Early diagnosis leads to appropriate life saving and symptom

reducing treatment

• Limited access to heart failure specialists− Need to target advanced treatments at high

risk patients

₤ Rates of hospitalisation remain high

Healthcare Commission. Pushing the boundaries: improving services for people with heart failure. London Healthcare Commission, 2007

Are we offering..........

Advanced Care or

Palliative Care

........... to our Patients with Heart Failure?

Currently (2009)….

Inequitable care

Only for the symptomatic patient seeking help

No more than Crisis management for the majority

Palliative Care that could be better !!

National drivers

Quality Outcomes Framework

‘Advancing Quality’ (NW SHA)

National HF database

Darzi report– Equitable, efficient, patient centred care– Health improvement (outcomes and quality)– Adherence to best practice (NICE, NSF)

Financial climate– Avoid hospital admission– Manage chronic disease in primary care

Our aim….‘Best care’ whenever and wherever patients require it ............

Not currently seeking attention

– Not yet diagnosed

– With confirmed diagnosis

New presentation

− In Primary Care with symptoms

Hospital admission(s)

− With severe heart failure

Our aim....

To demonstrate that optimal care is cost

saving...................

Failures?

•

• Routine management

• Advanced management

Diagnosis

Definition: The first problem

European society of Cardiology:

‘typically breathlessness or fatigue, either at rest or during exercise, or ankle swelling;

and objective evidence of cardiac dysfunction at rest (usually on

echocardiography)’

BLACKPOOL FYLDE AND WYRE HOSPITALS NHS FOUNDATION TRUST

LANCASHIRE CARDIAC CENTRE

Improving Diagnosis and Outcomes in Chronic Heart Failure

PROPOSAL 1

Patients presenting with breathlessness and patients on the listed chronic disease registers, attending for routine review, should be asked to complete an NYHA questionnaire while waiting to see the practice Nurse / doctor. Those whose answers suggest that they are in NYHA II or above should have a BNP test and be considered for referral to the one stop Heart Failure Diagnostic Clinic (HFDC) or open access echocardiography service.

NewYorkHeart Association

NYHA > IIFurther investigation required

Class Symptom

1 No limitation Ordinary physical activity does not cause tiredness, breathlessness, chest discomfort or palpitation (an unexpected awareness of your heartbeat).

2 Slight limitation You are comfortable at

rest but physical activity causes some tiredness, breathlessness, chest discomfort or palpitation (an unexpected awareness of your heartbeat).

3 Marked limitation You are comfortable at

rest, but everyday activities cause marked tiredness, breathlessness, chest discomfort or palpitation (an unexpected awareness of your heartbeat).

4 Inability to carry out any physical activity without discomfort

You have significant breathlessness or chest discomfort at rest. Any physical activity causes your symptoms to get worse.

BNP

Brain-type Natriuretic Peptide (BNP) is a hormone, secreted in the ventricular myocardium during periods of increased Atrial and ventricular wall tension

It is the most powerful marker of cardiovascular morbidity and mortality including sudden death

An elevated BNP indicates that the heart or kidneys are not working well but does not tell exactly why

NICE Guidance 2010

HIGH (>100)

‘VERY HIGH’ (>400) poor prognosis

Symptoms of HF

Previous MI?

Refer for urgent Echo and

Specialist assessment (within 2 weeks)

YES Check BNP

NO

Refer for Echo and specialist

assessment routinely

Prescribe Beta blocker and ACE inhibitor – use clinical judgement to decide which first

Those with PVD, impotence, DM, COPD without reversibility or interstitial lung disease should have cardioselective BB in the same way as other patients

HF licensed BB to replace other BB after LVSD diagnosed

No upper age limit

If mod – severe symptoms persist prescribe Aldosterone antagonist

If no contraindication, offer supervised exercise based rehab programme – within other rehab programme is OK

Include psychological and educational component

Ongoing management of all patients admitted to hospital should be guided by the opinion of a specialist in HF

Add Hydralazine / nitrate to black patients if remain symptomatic despite BB and ACE I

Consider adding ARB to ACE I / BB if aldo antag not tolerated – NB: specialist decision, monitoring of renal function and K req’d

Consider monitoring of BNP for some eg. Difficult uptitration, admission to hospital

Specialist advice for all:

Initial diagnosis Valve disease HFPEF COPD, CRF, anaemia, PVD, Ur. Freq, gout Angina, AF, other arrhythmia Pregnant/ considering pregnancy

HeartFailure DiagnosticClinic

One stopWithin 2 weeks

BLACKPOOL FYLDE AND WYRE HOSPITALS NHS TRUST

LANCASHIRE CARDIAC CENTRE HEART FAILURE DIAGNOSTIC CLINIC

If the patient does not meet one of the following criteria or has had echocardiogram in the last twelve months – please do not refer to One Stop HFDC

Refer to cardiology via usual channels or to the HF team directly by letter if previously known to them

REFERRAL FORM AND CHECKLIST

Please fax this referral and blood results if required to : Heart Failure Team Fax no: 01253 657845 or referral form initially to HFteam@bfwhospitals.nhs.uk

HEART FAILURE DIAGNOSTIC CLINIC IS A ONE STOP DIAGNOSTIC CLINIC FOR ANY PATIENT WITH SYMPTOMS/SIGNS SUGGESTIVE OF HEART FAILURE BUT NO PREVIOUS DIAGNOSIS

In addition to echocardiogram and in accordance with NICE guidelines the following will be considered : - The aetiology of heart failure and treatment if required of this condition - The need for additional diagnostic tests eg. stress echo, transoesophageal echo, angiogram - Pharmacological and non pharmacological therapy - The role of device therapy

Diagnosis and management plan will be discussed with a view to increasing patient engagement / compliance A ‘patient held’ record of diagnosis / management will be produced and recorded on a National HF database

This single visit to hospital will better support the subsequent management of the majority of pts in Primary Care

The management and surveillance of the most complex/at risk patients will be undertaken by the hospital HF team in consultation with their General Practitioner and the Community HF team

Patient details

Name :

Address :

Postcode :

Tel.no :

DOB :

NHS no :

Hospital no :

Referring GP

Name :

Address:

Tel. no :

Fax. no:

Referral date: PCT area :

Yes Details

The patient has symptoms suggestive of HF and history of myocardial infarction in the past

The patient has symptoms suggestive of HF and an elevated BNP or BNP is unavailable to your practice we are working with Cardiac Network to improve access

BNP result :

Hospital where assay performed:

APPOINTMENT AT HFDC WILL BE OFFERED WITHIN 2 WEEKS OF CHOOSE AND BOOK REFERRAL, RECEIPT OF COMPLETED REFERRAL FORM and if required (see above) BNP result

All patients should have had blood taken for U&E and FBC – result need not delay referral REFERRAL TO HFDC WILL BE ACCEPTED WITHOUT BLOODS FOR THOSE WITH ALARM FEATURES THIS IS OFFERED ONLY AS AN ALTERNATIVE TO HOSPITAL ADMISSION IF FELT APPROPRIATE

(please tick)

Heart Failure Diagnostic ClinicComprehensive specialist assessment

History/ examination

Echocardiogram

Consideration of need for further investigation – Angiogram, TOE, stress test

Management plan- Lifestyle- Pharmacological- Non pharmacological- Device therapy

Patient education / engagement

• HF referral poster• AQ data

Failures?

•

• Advanced management

Diagnosis

• Routine management

Failures?

•

• Advanced management

Diagnosis

• Routine management

Biventricular Pacemakers

Right AtrialLead

Right VentricularLead

ECG

• P wave• QRS duration

37

38

Biventricular Pacemakers

Right AtrialLead

Right VentricularLead

Left VentricularLead

Biventricular Pacemakers

Biventricular Pacemakers36% reduction

in All Cause Death / CVS death in All Cause Death / CVS death /Hospitalisation/Hospitalisation

CARE – HF: Cleland et al, NEJM, 2005

• Referral for CRT from North Lancs/ Blackpool

Transplant vs. medical Rx

Butler et al. J Am Coll Cardiol, 2004

Cardiopulmonary exercise testing

Survival following cardiac transplant

• 1 year: 85%• 5 years: 73%• 10 years: 58%

www.uktransplant.org.uk

Mechanical support: Ventricular assist devices

Inflow: LV/LA

Outflow: Ao

• Bridge to transplant

• Bridge to recovery

• Destination therapy

Who should receive a VAD as bridge to transplant?

Heart Failure Service - Blackpool

Timely and accurate diagnosis One stop diagnostic clinic

Appropriate/safe/rapid referral pathways Identify high risk patients BNP

Efficient and effective clinical care Treatment optimisation (NICE) Non pharmacological intervention (CRT / ICD, LVAD, Tx)

Communication , Communication, Communication

Community Heart Failure Service

• Uptitration to maximal tolerated medical therapy

• Ongoing surveillance / management of those at high risk of readmission

• Discharge to GP of stable patients

Hospital Discharge

HIGH RISK GROUP

New presentation

to GP

Known diagnosis in

Primary Care

Specialist Consultant led clinic to see all high risk patients ie. :• LBBB on ECG• New AF• Angina• Any ongoing symptoms despite

maximal tolerated medical therapyAll patients should have routine 6 monthly review of:• Symptoms• Medication• ECG: LBBB, AF, HR• UE, FBC

Specialist Consultant led

HF clinicHIGH RISK

GROUPReferral by: • Direct letter• HF helpline

01253 657865

• Advice required• High risk

(see markers below)• Unable to achieve

target dose of medication

Heart Failure One stop

Diagnostic clinic• See referral form• Seen within 2 weeks• Aim discharge with

management plan for majority

• HF helpline

BNP ? Yes

GP follow up• Uptitration to

maximal tolerated medical therapy

• Ongoing surveillance

No

Previous MI?

> threshold

Key

___ Patient numbers to be continually audited and reported by Acute Trust

* Final achievement of target medicaltherapy doses to be periodically auditedand reported by Acute Trust

*

Acute Trust HF nurse also available for advice

/ to facilitate seamless careHF helpline:

01253 303269

In order to reduce risk of readmission all inpatients will be seen during admission or early post discharge by specialist team

Attached

HFDC referral formDischarge report (example)Uptitration advice form

Thank youAny questions?