Heart Failure Chronic heat failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the pumping ability of the heart. Typically, the heart is damaged as a result of ischaemic heart disease, hypertension, cardiomyopathy, arrhythmias, valve disease resulting from rheumatic fever or other causes, congenital heart disease, endocarditis, myocarditis, or as the result of damage by alcohol, drugs etc. National Collaborating Centre for Chronic Conditions. (NCCCC). Chronic heart failure: Management of Chronic heart Failure in Adults in primary and Secondary Care. Available at www.rcplondon.ac.uk/college/ceeu/ncccc_index.htm and www.nice.org.uk and on the website of the National Electronic Library for Health www.nelh.nhs.uk There are two main types of heart failure: heart failure with reduced systolic function and heart failure with preserved systolic function, often termed “diastolic heart failure”. Systolic heart failure occurs when the heart’s ability to contract deteriorates and it lacks the force to eject sufficient blood into the circulation. In this situation, blood entering the heart from the lungs’ may accumulate with subsequent pressure causing fluid to leak into the surrounding tissue (pulmonary congestion). Systolic dysfunction is the most common cause of heart failure occurring in 60-80% of patients. Diastolic heart failure is a result of stiffening of the heart muscle that reduces the heart’s ability to relax and fill with blood. Diastolic dysfunction is the cause of 20-40% of heart failure cases.

Chronic Heart Failure A complex syndrome resulting from any structural or functional cardiac disorder that impairs the pumping ability of the heart Systolic Heart Failure (LVSD) (60-80%) Diastolic Heart Failure (HFPEF) (20-40%) Affects 1-2% of the population - Av age at presentation 76 years UK - Nearly 1 million with symptoms / Similar no. asymptomatic Prevalence expected to rise through a combination of: Improved survival of people with ischaemic heart disease More effective treatments for heart failure Effects of population ageing Chronic heat failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the pumping ability of the heart. Typically, the heart is damaged as a result of ischaemic heart disease, hypertension, cardiomyopathy, arrhythmias, valve disease resulting from rheumatic fever or other causes, congenital heart disease, endocarditis, myocarditis, or as the result of damage by alcohol, drugs etc. National Collaborating Centre for Chronic Conditions. (NCCCC). Chronic heart failure: Management of Chronic heart Failure in Adults in primary and Secondary Care. Available at www.rcplondon.ac.uk/college/ceeu/ncccc_index.htm and www.nice.org.uk and on the website of the National Electronic Library for Health www.nelh.nhs.uk There are two main types of heart failure: heart failure with reduced systolic function and heart failure with preserved systolic function, often termed “diastolic heart failure”. Systolic heart failure occurs when the heart’s ability to contract deteriorates and it lacks the force to eject sufficient blood into the circulation. In this situation, blood entering the heart from the lungs’ may accumulate with subsequent pressure causing fluid to leak into the surrounding tissue (pulmonary congestion). Systolic dysfunction is the most common cause of heart failure occurring in 60-80% of patients. Diastolic heart failure is a result of stiffening of the heart muscle that reduces the heart’s ability to relax and fill with blood. Diastolic dysfunction is the cause of 20-40% of heart failure cases.

Aetiology Main causes Coronary disease Hypertension Valvular Undetermined (no angiographic data) (10%) Main causes Coronary disease Hypertension Valvular Cardiomyopathy Alcohol Viral Drugs Post Partum Cor Pulmonale Idiopathic (no CAD) (13%) Other (5%) AF alone (3%) Coronary artery disease (52%) In a community based study conducted in south London, all incident cases of heart failure in a population of 292 000 were identified by monitoring patients admitted to hospital and through a rapid access heart failure clinic. The presence and severity of coronary artery disease was identified by coronary angiography in patients under 75 years. Myocardial perfusion scanning was used to elucidate the aetiological significance of the coronary artery disease and identify hibernating myocardium. 332 cases of new heart failure were identified over 15 months. 136 of these cases were under 75 years and angiography was undertaken in 99/136 (73%). Coronary artery disease was the aetiology in 71/136 (52%). In 18 of these 71 cases (25%), the aetiology was not recognised to be due to coronary artery disease prior to angiography, including eight cases with hibernating myocardium. Overall, this suggests that coronary artery disease is the cause of 52% (95% CI 43-61%) of incident heart failure in the general population under 75 years. Clinical assessment without angiography under-estimates the proportion of patients with coronary artery disease, and fails to identify those patients who may benefit from revascularization. Fox KF, Cowie MR, Wood DA, et al. Coronary artery disease as the cause of incident heart failure in the population. Eur Heart J 2001;22:228-36. Alcohol (4%) Valve disease (10%) Results based on full investigation (including coronary angiography) in new patients aged <75 years identified in a UK population-based study Hypertension alone (4%) Fox et al, Eur. Heart J., 2001

Chronic Heart Failure Quality Standard 2011 Heart failure has a poor prognosis: 30 – 40% of patients diagnosed with heart failure die within 1 year There after the mortality is <10% per year Heart Failure accounts for 2% of all NHS inpatient bed days and 5 % of all emergency medical admissions Readmissions are common – about 25% of patients are readmitted within 3 months

Financial burden of heart failure 1 million inpatient bed days 2% of all NHS inpatient bed-days 5% of all emergency medical admissions to hospital 1.8% of total NHS budget NICE clinical guideline 108 Management of chronic heart failure in adults in primary and secondary care

The poor prognosis of heart failure Mortality is 40% by 12 months after new diagnosis 10% per year thereafter Median survival: 3 years from diagnosis Data from the Hillingdon Heart Failure Study also show that around 40% of people die within one year of a diagnosis of heart failure. The average life-expectancy was only about 3 years following a diagnosis, which is much worse than for many other serious illnesses, for example, cancers of the breast, uterus, prostate and bladder, and very similar to that for cancer of the colon. Cowie MR, Wood DA, Coats AJ et al. Survival of patients with a new diagnosis of heart failure: a population based study. Heart 2000;83:505-10. Petersen S, Rayner M, Wolstenholme J. Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation, 2002. In 1995 , mortality in the UK 6 months following a diagnosis of heart failure was 26% In 2005 this had improved to 14% Cowie et al, Heart, 2000

More recent hospital data UK data (April 2010–March 2011) 85% of hospitals 36,054 records Median length of stay by hospital 11.6% inpatient mortality: 51% dead or readmitted by 306 days Hospitals (n=176) 0 5 10 15 20 Length of stay (median) in days National Heart Failure Audit. National Institute for Cardiovascular Outcomes Research, University College London, 2012 Available at: http://www.ucl.ac.uk/nicor/audits/heartfailure/additionalfiles/pdfs/annualreports/annual11.pdf

5: Education and self-management Primary care presentation 1: Urgent referral for people with previous myocardial infarction 2: Measuring serum natriuretic peptides Assessment and diagnosis 3: 2-week assessment and diagnosis 4: 6-week assessment and diagnosis Management 6: Multidisciplinary heart failure team 7: Treatment with ACE inhibitors, ARBs and BB 8: Cardiac rehabilitation programme 9: Monitoring stable chronic heart failure Admitted patients 10: Management plans for people admitted to hospital 11: Contribution of multidisciplinary heart failure team to management plans 12: Hospital discharge and follow-up care Moderate to severe chronic heart failure 13: Specialist and palliative care for people with moderate to severe chronic heart failure Information 5: Education and self-management Information NICE Quality Standard for CHF (2011)

Symptoms

Symptoms Exertional breathlessness Orthopnoea / nocturnal dyspnoea Peripheral oedema –”weeping legs” Lethargy and tiredness Postural dizziness

Aims of treatment Increase exercise capacity – reduce breathlessness Improve sleep – reduce nocturnal dyspnoea and orthopnoea Improve mobility – reduce peripheral oedema Improve tiredness and lethargy – improved sleep patterns and expectations Reduce postural dizziness

Once a diagnosis of heart failure has been made, the severity of symptoms and level of incapacity can be categorised according to the New York Heart Association (NYHA) classification. This classification recognises four classes in which symptoms increase in severity, increasingly limiting the ability of patients to undertake normal daily activities. Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001;22:1527–60. CLASSIFICATION

The NYHA Symptom Based Classification No limitations on activity. No fatigue, breathlessness or palpitation on ordinary physical activity Annual mortality 3-5% Class II Patients are comfortable at rest but ordinary physical activity such as climbing stairs or doing housework results in symptoms ‘Mild’ heart failure Annual mortality 10% Class III Patients have a marked limitation of physical activity. Although patients are comfortable at rest, less than ordinary physical activity will lead to symptoms ‘Moderate’ heart failure Annual mortality 12-16% Class IV Patients have symptoms even at rest and are unable to undertake any physical activity without discomfort ‘Severe’ heart failure Annual mortality 15-20% Worse prognosis than most cancers Once a diagnosis of heart failure has been made, the severity of symptoms and level of incapacity can be categorised according to the New York Heart Association (NYHA) classification. This classification recognises four classes in which symptoms increase in severity, increasingly limiting the ability of patients to undertake normal daily activities. Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001;22:1527–60.

The Natural History of Heart Failure

Once a diagnosis of heart failure has been made, the severity of symptoms and level of incapacity can be categorised according to the New York Heart Association (NYHA) classification. This classification recognises four classes in which symptoms increase in severity, increasingly limiting the ability of patients to undertake normal daily activities. Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001;22:1527–60. DIAGNOSIS

Electrocardiogram Heart Failure is very unlikely in the presence of a normal ECG An abnormal ECG suggests further investigation required Predictors of Systolic Dysfunction Anterior Q waves LBBB Left atrial enlargement Left ventricular hypertrophy Atrial fibrillation Heart failure is most unlikely in a patient in the presence of a normal ECG. Normal results may, therefore, be useful in guiding the doctor to consider other diagnoses and investigations. Any abnormality of the initial 12-lead ECG, does not confirm a diagnosis of heart failure and further investigation is required. The sensitivity of the ECG will depend upon what features are considered abnormal and the experience of the ECG reader, and may be as high as 94%. National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at www.rcplondon.ac.uk/college/ceeu/ncccc_index.htm and www.nice.org.uk and on the website of the National Electronic Library for Health www.nelh.nhs.uk NICE, 2003

BNP and NT- pro BNP Excellent Rule Out Test – Measure of Disease Activity Certain conditions can Reduce BNP Drugs - diuretics, ACE inhibitors, beta-blockers, ARBs and aldosterone antagonists Certain Conditions increase BNP LVH Ischaemia Right ventricular overload and hypoxaemia (including PE) GFR < 60 ml/minute Sepsis COPD, Diabetes and liver cirrhosis Increasing age particularly > 75

Diagnosing Heart Failure (NICE 2010)

Once a diagnosis of heart failure has been made, the severity of symptoms and level of incapacity can be categorised according to the New York Heart Association (NYHA) classification. This classification recognises four classes in which symptoms increase in severity, increasingly limiting the ability of patients to undertake normal daily activities. Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001;22:1527–60. TREATMENT

Diuretic therapy for heart failure Rapid relief of congestive symptoms and fluid retention No evidence for mortality benefit No effect on disease progression Drug Initial dose (mg) Maximum recommended daily dose (mg) Loop diuretics Bumetanide Furosemide 0.5–1.0 20–40 5–10 250–500 Thiazides* Bendroflumethiazide (bendrofluazide) Metolazone 2.5 5 10 Diuretics remain a key element in the treatment of heart failure, mainly for relief of symptoms. Diuretics improve symptoms (breathlessness) and exercise performance in patients with heart failure. Patients with symptomatic heart failure often deteriorate (increased body weight, reduced walking distance and progressively worsening quality of life) when diuretic therapy is withdrawn. Diuretics preceded the advent of randomised control trials, and there are therefore no large or long-term placebo controlled trials of their use. They have shown no benefit in terms of improvements in mortality or disease progression. National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at www.rcplondon.ac.uk/college/ceeu/ncccc_index.htm and www.nice.org.uk and on the website of the National Electronic Library for Health www.nelh.nhs.uk

Diuretic Resistance Progression of heart failure Excessive Sodium Consumption Excessive Fluid Intake NSAIDS Tactics to overcome Increased dose, increase frequency Combine loop and thiazide Concurrent ACE or aldosterone antag. Monitor renal function carefully !

Treating Heart Failure (NICE 2010)

First-line treatment for LVSD Offer both ACE inhibitors and beta-blockers licensed for heart failure to all patients with LVSD Offer beta-blockers licensed for heart failure to all patients with LVSD, including older adults and patients with peripheral vascular disease erectile dysfunction diabetes mellitus interstitial pulmonary disease COPD without reversibility NOTES FOR PRESENTERS: Key points to raise: Offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first. [new 2010] [1.2.2.2] Offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including older adults and patients with: peripheral vascular disease, erectile dysfunction, diabetes, mellitus, interstitial pulmonary disease and chronic obstructive pulmonary disease (COPD) without reversibility. [new 2010] [1.2.2.7] Additional information: The following recommendations are related Start ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target dose is achieved. [2010] [1.2.2.5] Measure serum urea, creatinine, electrolytes and eGFR at initiation of an ACE inhibitor and after each dose increment1.  [2010] [1.2.2.6]  Introduce beta-blockers in a ‘start low, go slow’ manner, and assess heart rate, blood pressure, and clinical status after each titration. [2010] [1.2.2.8] Switch stable patients who are already taking a beta-blocker for a comorbidity (for example, angina or hypertension), and who develop heart failure due to left ventricular systolic dysfunction, to a beta-blocker licensed for heart failure. [new 2010] [1.2.2.9] There are also two recommendations about alternative first-line treatment for patients who are intolerant of ACE inhibitors. Consider an ARB licensed for heart failure as an alternative to an ACE inhibitor for patients with heart failure due to left ventricular systolic dysfunction who have intolerable side effects with ACE inhibitors. [new 2010] [1.2.2.14]. See recommendation 1.2.2.15 relating to the monitoring of patients with heart failure who are taking an ARB Seek specialist advice and consider hydralazine in combination with nitrate for patients with heart failure due to left ventricular systolic dysfunction who are intolerant of ACE inhibitors and ARBs [new 2010] [1.2.2.13] For more information about the first-line treatment of heart failure due to LVSD see pages 6 and 7 of the quick reference guide and slide 18 Footnote  1. For practical recommendations on treatment with ACE inhibitors see ‘Chronic kidney disease’ (NICE clinical guideline 73).

Second-line treatment for LVSD Seek specialist advice and consider adding one of the following if patient remains symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker: aldosterone antagonist licensed for heart failure (especially in NYHA class III–IV or MI in past month) ARB licensed for heart failure (especially in NYHA class II-III) hydralazine in combination with nitrate (especially in people of African or Caribbean origin with NYHA class III-IV) NOTES FOR PRESENTERS: Key points to raise: This key priority is a new recommendation and represents a change in practice. The recommendation is based on evidence of better outcomes for particular second-line treatments in certain subgroups. The recommendation is given in full below. Seek specialist advice and consider adding one of the following if a patient remains symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker: an aldosterone antagonist licensed for heart failure (especially if the patient has moderate to severe heart failure [NYHA 1 class III–IV] or has had an MI within the past month) an angiotensin II receptor antagonist (ARB) licensed for heart failure2 (especially if the patient has mild to moderate heart failure [NYHA class II–III]) or hydralazine in combination with nitrate (especially if the patient is of African or Caribbean origin3 and has moderate to severe heart failure [NYHA class III–IV]) [new 2010] [1.2.2.4] Additional information: The following recommendation is also related to the second-line treatment of heart failure due to left ventricular systolic dysfunction. Seek specialist advice before offering second-line treatment to patients with heart failure due to left ventricular systolic dysfunction. [new 2010] [1.2.2.3] Recommendations 1.2.2.10, 1.2.2.11, 1.2.2.12 and 1.2.2.15 are also about the use of second-line treatments for heart failure due to LVSD. For more information about these recommendations see the NICE guideline. For more information about the second-line treatment of heart failure due to LVSD see pages 6 and 7 of the quick reference guide and slide 18 Footnote 1. New York Heart Association Classification of heart failure 2. Not all ARBs are licensed for use in heart failure in combination with ACE inhibitors 3. This does not include mixed race. For more information see the full guideline www.nice.org.uk/guidance/CG108/NICEGuidance/doc/English

When to refer to the specialist Refer patients to the specialist heart failure : for the initial diagnosis of heart failure for the management of severe heart failure (NYHA class IV), heart failure that does not respond to treatment or heart failure that can no longer be managed at home when they are planning a pregnancy or are pregnant when they have heart failure due to valve disease  NOTES FOR PRESENTERS: These are NOT key priorities for implementation, but have been included to highlight when patients should be referred to the specialist multidisciplinary heart failure team Key points to raise: Refer patients to the specialist multidisciplinary (MDT) heart failure team for: the initial diagnosis of heart failure and 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. [new 2010] [1.5.1.1] In women of reproductive age who have heart failure, contraception and pregnancy should be discussed. If pregnancy is being considered or occurs, specialist advice should be sought. Subsequently, specialist care should be shared between the cardiologist and obstetrician. [2003] [1.2.2.31] Patients with heart failure due to valve disease should be referred for specialist assessment and advice regarding follow-up. [2003] [1.2.2.26] See page 4 of the quick reference guide and slide 17 for more information about the involvement of the specialist multidisciplinary team in the diagnosis of chronic heart failure. Additional information: Related recommendation: When a patient is admitted to hospital because of heart failure, seek advice on their management plan from a specialist in heart failure. [1.4.1.5] Some patients may also require referral to the specialist multidisciplinary heart failure team for consideration of invasive procedures such as cardiac transplantation, cardiac resynchronisation therapy (in line with NICE technology appraisal guidance 120 [2007] or implantable cardioverter defibrillators (in line with NICE technology appraisal guidance 95 [2006]). Please refer to the NICE website for updates on the review status of these appraisals.

INTERVENTION

Surgical and device treatment options for chronic heart failure Coronary revascularisation (PCI/CABG) Cardiac resynchronisation therapy (CRT) Implantable cardioverter defibrillator (ICD) Left ventricular assist device (LVAD) Transplantation Although drug therapy is the mainstay of treatment of heart failure, some patients will also benefit from diagnostic or interventional invasive procedures. These procedures are normally organised by a specialist. Several RCTs are currently examining the benefit of such procedures, and the evidence base is likely to change substantially in the next 5–10 years. The NICE guideline has only general advice; specialist advice is needed where procedures such as those listed here might be considered. National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at www.rcplondon.ac.uk/college/ceeu/ncccc_index.htm and www.nice.org.uk and on the website of the National Electronic Library for Health www.nelh.nhs.uk NICE, 2003

Implantable Cardiac Defibrillators Therapies Relative Risk Reduction Mortality 2 year ACE-I 23% 27% Β-Blockers 35% 12% Aldosterone Antagonists 30% 19% ICD 31% 8.5%

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