TREATING ANAEMIA IN HEART FAILURE CLINICAL AUDIT MARYANNE MARIYASELVAM, S JAFFERY AND R NATA

The Queen Elizabeth Hospital, Kings Lynn

Heart Failure

Failure of the heart as a pump to support physiological circulation Systolic Heart failure: Reduced cardiac contractility Diastolic Heart Failure: Impaired cardiac relaxation and abnormal

ventricular filling

Symptoms: Breathlessness (exertional dyspnoea, orthopnoea and paroxysmal

nocturnal dyspnoea) Fatigue Ankle swelling

Causes:

Coronary artery disease (mostly MI) Hypertension AF

Why is it a problem?

Affects 900,000 people in the UK 1 in 35 people aged 65–74 years has heart failure 1 in 15 of those aged 75–84 years 1 in 7 in those aged 85 years and above

Poor prognosis

In 2009 12% in patient mortality 30-40% of patients die in the first year

Costs to NHS 1 million inpatient bed days and 2% of all NHS inpatient bed-days 5% of all emergency medical admissions to hospital. There is a 50% projected to rise to admissions over the next decade 2% of the total NHS budget

70% is due admissions 7-8 days average stay 1 in 4 patients are readmitted in three months

Anaemia

Anaemia is a common co-morbidity in heart failure 38% of patients with diastolic dysfunction 41% of patients with systolic dysfunction

Associated with: Increased disease severity Reduced function status and poor quality of life

Consistently shown to be an independent risk factor

Higher New York Heart Association health class Hospital admissions Mortality

What causes anaemia

Haemodilution Aspirin and oral anticoagulation microscopic gastrointestinal

blood loss Salt and Water retention increased plasma volume eGFR of <60 reduced EPO production

Drug therapy ACE inhibitors and ARBs associated with decreased production.

Iron deficiency Reduced uptake of iron, folic acid and vitamin B12 Iron deficiency can result from its defective release from cells

Chronic disease Raised pro-inflammatory markers in the blood are inversely

related to haemoglobin concentration and disruption erythropoiesis mechanism

What causes anaemia

Current Guidelines

Treating anaemia: Improve left ventricular ejection fraction, Improve exercise tolerance Improve quality of life May prevent hospital admissions

No guidelines NICE No recommendations Literature

blood transfusion is not recommended as treatment EPO stimulation agents Increase iron

Audit

Hb <13g/dl in men Hb <12g/dl in women

Haematinics:

Hb, mean corpuscular volume (MCV) B12, folate Iron, iron binding capacity, ferritin Thyroid stimulating hormone

Criteria Standard All anaemic patients with Heart Failure should have their haematinics checked

100%

Audit Methods

Number of admissions of patients in heart failure over 2 months (1/12/11 – 31/1/12) Admission Haemoglobin level was checked All patient’s blood results were checked up to 6 months

prior to admission and throughout their admission to determine if haematinics were measured.

All patient’s inpatient drug charts were checked to determine whether any treatment was instigated.

Audit Results

59 admissions with heart failure 34 patients were anaemic (58%) 20% patient’s had their haematinics checked 32% were treated

Number of admissions with Heart Failure

Number of Anaemic patients with Heart Failure

Haematinics checked

Anything prescribed pre/during admission

Men 31 17 2 6 Women 28 17 5 5

Change Implemented

Results presented at a local level

Highlighted the importance of checking haematinics to junior staff

If a cause is found then treatment should be started

Re Audit Methods

Number of admissions of patients in heart failure over 3 months (1/7/12 – 30/9/12 ) Admission Haemoglobin level was checked All patient’s blood results were checked up to 6 months

prior to admission and throughout their admission to determine if haematinics were measured.

All patient’s inpatient drug charts were checked to determine whether any treatment was instigated.

Re Audit Results

66 admissions with heart failure 35 patients were anaemic (53%) 71% patient’s had their haematinics checked 20% were treated

Number of admissions with Heart Failure

Number of Anaemic patients with Heart Failure

Haematinics checked

Anything prescribed pre/during admission

Men 36 14 11 4 Women 30 21 14 4

Measuring against standards

Criteria Standard Audit Reaudit

All anaemic patients with Heart Failure should have their haematinics checked

100% 20% 71%

All patients should have their anaemia treated

100% 32% 20%

Iron deficiency anaemia

Audit results All 11 patients that were treated were iron deficient 1 was treated with IV iron

Re Audit results 7/8 patients that were treated were iron deficient 3 were treated with IV iron

Intravenous Iron

Improvement seen in Quality of life

Patient global assessment

Left Ventricular Ejection Fraction. New York Health Association functional class. Exercise capacity

Improvements seen in treadmill exercise duration

Some studies have claimed a reduction in hospitalizations after Rx with IV iron.

Ferric Carboxymaltose in Patients with Heart Failure and Iron Deficiency

Intravenous Iron Reduces NT-Pro-Brain Naturitic Peptide in Anaemic Patients with Chronic Heart Failure and Renal Insufficiency

Final Changes Implemented

Introduction of a outpatient IV iron service Patients found to be iron deficient and not treated during

their inpatient stay can be invited back to receive iron infusion over a few weeks

GPs may also refer to this service if their patients are found to be iron deficient

Conclusions

Average of one admission a day with heart failure 50% of these patients are anaemic

Junior staff are poor at checking results and acting on them

Teaching junior staff Poster reminders 60% improvement in checking results 0% improvement in acting on these results

Outpatient IV service seeks to improve treatment of iron

deficiency anaemia We will need to re audit to determine whether this affects

actual numbers of hospital admissions.

References Klip IT, Comin-Colet J, Voors AA, Ponikowski P, Enjuanes C, Banasiak W, Lok DJ, Rosentryt P, Torrens A, Polonski L,

van Veldhuisen DJ, van der Meer P and Jankowska EA. Iron deficiency in chronic heart failure: An international pooled analysis. American Heart Journal. 2013; 165:575-582

Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJV, Ponikowski P, Poole-Wilson PA, Stro¨mberg A, van Veldhuisen DJ, Atar D, Hoes AW, Keren A, Mebazaa A, Nieminen M, Priori SG, Swedberg K, ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal 2008;29:2388–2442

Drakos, SG, Anastasiou-Nana MI, Malliaras KG, Nanas JN. Anemia in Chronic Heart Failure Review Paper Congestive Heart Failure. 2009;15(2):87-92

Chronic Heart Failure. National clinical guideline for diagnosis and management in primary and secondary care August 2010 NICE Clinical Guideline No 108

van der Meer P, Postmus D, Ponikowski P, Cleland JG, O'Connor CM, Cotter G, Metra M, Davison BA, Givertz MM, Mansoor GA, Teerlink JR, Massie BM, Hillege HL, Voors AA. The predictive value of short-term changes in hemoglobin concentration in patients presenting with acute decompensated heart failure. Journal of the American College of Cardiology 2013; 61(19):1973-81

He SW, Wang LX. The Impact of Anaemia on the Prognosis of Chronic Heart Failure: A Meta-Analysis and Systemic Review. Congestive Heart Failure. 2009;15(3):123-30

Anker SD, Comin Colet J, Filippatos G, et al. Ferric Carboxymaltose in Patients with Heart Failure and Iron Deficiency. N Engl J Med 2009;361:2436-2448

Toblli, JE, Lombraña A, Duarte P, Di Gennaro, F. Intravenous Iron Reduces NT-Pro-Brain Natriuretic Peptide in Anemic Patients With Chronic Heart Failure and Renal Insufficiency. Journal of the American College of Cardiology. 2007;50(17):1667-65

Thank you for listening

Erythropoiesis stimulating agents - evidence These were introduced for the treatment of anaemia associated with chronic kidney disease Used to elevate red blood cell levels without the use of blood transfusions Subsequent trials have shown that targeting higher Hb concentrations has shown no

improvement in clinical outcomes. The Normal Haematocrit Study

initially suggested using ESA to raise Hb could cause harm. 1233 patients with congestive cardiac failure or IHD who undergoing dialysis were enrolled into the study

to receive increasing doses of EPO to reach and maintain a normal haematocrit value. This trial was halted, because at 14 months follow up 33% of patients in the normal haematocrit group

had died or had a non fatal MI compared with 27% of the low haematocrit group. The CHOIR trial

1432 patients to receive epoetin alfa treatment sufficient to achieve and maintain a hemoglobin target of either 13.5 or 11.3 g per deciliter

At 16 months the high Hb group showed a 17.5% incidence of death, MI, hospitalisation for congestive heart failure, stroke, compared with 13.5 of patients in the low Hb group.

REDHOT trial Similarly showed no mortality benefit.