Chronic heart failure By Vishal Patel GPVTS1

Objectives Definition Classification Types Diagnosis Management Referral

Definition Efficiency of the heart pump is impaired Structural Functional Around 900,000 people in the UK have heart failure   Almost as many have damaged hearts but, as yet, no symptoms of heart failure Both the incidence and prevalence of heart failure increase steeply with age, with the average age at first diagnosis being 76 years

Common causes in UK CAD HTN, MI, cardiomyopathy, valvular, arrhythmias

Q) How many people have HF in the UK? B – 500,000 C – 900,000 D – 1.2 million

Q) How many people have HF in the UK? B – 500,000 C – 900,000 D – 1.2 million

900,000 have HF Average 30 patients/GP

Presenting symptoms Asymptomatic Common symptoms SOB, oedema, fatigue Incidence & prevalence increase with age 76 years Around 900,000 people in the UK have heart failure   Almost as many have damaged hearts but, as yet, no symptoms of heart failure Both the incidence and prevalence of heart failure increase steeply with age, with the average age at first diagnosis being 76 years

Q) What percentage of patients die within the first year of diagnosis? B 10 – 20% C 20 – 30% D 30 – 40%

Q) What percentage of patients die within the first year of diagnosis? B 10 – 20% C 20 – 30% D 30 – 40%

Poor prognosis 30 - 40% mortality in 1st year <10% per year thereafter

Classification NYHA New York Heart Association Functional Classification

Types of HF Two types Left ventricular systolic dysfunction (LVSD) Reduced EF Impaired contraction Preserved EF Impaired left ventricular relaxation Heart failure due to left ventricular systolic dysfunction (LVSD) This is caused by impaired left ventricular contraction, and is usually characterised by a reduced left ventricular ejection fraction. Heart failure with preserved ejection fraction (HFPEF) This 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.

Diagnosis/Investigations ECG, CXR Bloods test: FBC, U&E, eGFR, TFT, LFT, lipids, glucose, urinalysis, peak flow/ spirometry Serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NTproBNP]) Without previous MI

Q) For patients with i) previous MI and Q) For patients with i) previous MI and ?heart failure or ii) raised BNP When should this patient be assessed by a specialist? A – 2 weeks B – 4 weeks C – 2 months D – routine referral

Q) For patients with i) previous MI and Q) For patients with i) previous MI and ?heart failure or ii) raised BNP When should this patient be assessed by a specialist? A – 2 weeks B – 4 weeks C – 2 months D – routine referral

Previous MI & suspected HF, refer for ECHO and specialist assessment within 2 weeks.

Diagnosis/Investigations BNP hormone Released in response to changes in the heart Can be used to diagnose or monitor HF BNP/NT-proBNP Not interchangeable

Q) What level of BNP warrants a referral? C >400 D >500

Q) What level of BNP warrants a referral? C >400 D >500

Diagnosis/Investigations BNP >400 or NNTproBNP >2000 Urgent referral, ECHO, specialist assessment within 2 weeks Levels lower ACEI, b blockers, ARB’s, aldosterone antagonists Levels higher LVH, hypoxaemia, renal dysfunction, COPD, sepsis, diabetes, >70 years old, liver cirrhosis.

ECHO

Q) What drug type is not the first line treatment for heart failure? A – Aldosterone antagonists B - B blockers C - Diuretics D - ACE I

Q) What drug type is not the first line treatment for heart failure? A – Aldosterone antagonists B - B blockers C - Diuretics D - ACE I

Treatment LVSD HF preserved EF ACEI, beta blockers +/-Diuretics Diuretics only

Treatment Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure. Lifestyle: stop smoking, stop alcohol, Yearly flu vaccine Pneumococcal vaccine once

Aspirin in patients with HF & Consider anticoagulants in patients with Hx VTE, LV aneurysm or intra cardiac thrombus Aspirin in patients with HF & CAD Atherosclerotic arterial disease.

When to refer?

When to refer For the initial diagnosis of heart failure the management of: severe heart failure (NYHA class IV) heart failure that does not respond to treatment heart failure that can no longer be managed effectively in the home setting.  Previous MI and signs of HF 2 weeks

Worsening / severe HF due to LVSD Symptomatic despite: ACE I and B blocker. Worsening / severe HF due to LVSD Despite on 1st and 2nd line meds HF due to valvular disease

Q) How often should we monitor stable HF patients? A - 3 monthly B - 6 monthly C - yearly D - when the EMIS/SystmOne prompts me

Q) How often should we monitor stable HF patients? A - 3 monthly B - 6 monthly C - yearly D - when the EMIS/SystmOne prompts me

Q) How often should we monitor stable HF patients? A - 3 monthly B - 6 monthly C - yearly D - when the EMIS/SystmOne prompts me

Monitoring If stable, at least 6 monthly Bloods: U&E, eGFR Medication review a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status

References http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp#.WLvyzm_yjIU https://www.bhf.org.uk/heart-health/conditions/heart-failure https://www.nice.org.uk/guidance/Cg108 https://cks.nice.org.uk/heart-failure-chronic Oxford handbook of General Practice 4th Edition

Questions?