Heart failure MANAGEMENT IN THE COMMUNITY Sukhan Wilkins Lead Heart Failure Nurse, ACERS

Background Clinical syndrome that results from any structural or functional cardiac disorder that reduces the ability of the heart to function as a pump Around 1-2 million people in UK have HF Increasing prevalence; CHD and hypertensive heart disease, aging population Costs NHS around £625m per year, accounts for 5% of medical admissions to acute care Half of service users admitted with HF are readmitted within 3 months (NICE 2010).

HF risk factors MI CHD Congenital heart disease Age HTN Diabetes BMI Smoking Elevated LDL Alcohol Sleep apnoea AF Ethnicity Gender MESA study black participant had lower incidence of HFpEF compared to white. Females less risk of HFrEF, but more likely to develop HFpEF than males

Diagnostic pathway Recorded prevalence of HF in London 0.32-0.75%, national average 0.79% City and Hackney 1879 patients with heart failure on GP practice registers, prevalence rate 0.6% (2014/15 QOF) Average cost of echocardiography £135 BNP testing recommended by NICE as cost effective tool for diagnosis (costing average £30 per test).

N-terminal pro-B-type natriuretic peptide (NTproBNP) Level does not differentiate between HFpEF and HFrEF <400ng/L in those untreated means HF diagnosis unlikely 400-2000ng/L; refer for specialist assessment and echo within 6 weeks >2000ng/L ;within 2 weeks Obesity, Afro-Caribbean origin and HF meds can reduce BNP Age >70, LVH, ischaemia, tachycardia, CKD, COPD, diabetes, cirrhosis liver can raise BNP.

Why co-ordinated care by community HFSN is needed Average HF admission costs £3796* Effective community care known to reduce admission rates In London, 56% of patients are referred to HF nurse service, 18% referred for cardiac rehab*. *London Clinical Network/NHS England 2018

Aims of our service Optimising disease modifying meds in timely manner, under close monitoring More people feeling supported to self manage condition, less anxious and more in control, accessible & personalised information/advice Multidisciplinary specialist care Greater levels of access to appropriate services Fewer inappropriate hospital admissions and readmissions.

Service model Nurse led service, integrated with ACERs team Cardiorespiratory nurse consultant, lead HF nurse, 4 community HFSN, 1 inpatient HFSN, 1 cardiorespiratory assistant practitioner, 1 admin assistant Care delivered via GP based clinics, St Leonards, Homerton and Fountayne Road Health Centre, home visits for housebound 9-5, Monday to Friday, excluding bank holidays.

Referral Criteria Adults registered with a City and Hackney GP, or resident but not registered with any GP All patients should have confirmed diagnosis of heart failure by echo and raised NT-proBNP if done Aged 18 and over.

When to refer New diagnosis Difficult to control symptoms Following hospital admission for HF Referrals accepted from all primary, community & secondary HCPs, and via eRS (choose and book).

What can community HFSN offer? HFrEF - optimise evidence based HF medication as per guidelines HFpEF - follow cardiologist management plan to treat symptoms, manage co-morbidities Link to cardiologists at HUH, weekly meeting to discuss management complex patients Refer for device therapy Decompensation unable to be managed safely in community, arrange hospital admission through inpatient HF nurse Work closely with wider MDT, including respiratory, oxygen, CR, psychology, palliative teams.

Management 1 hour assessment to include education, tailored self care and lifestyle advice Consultations entered direct on EMIS same day, any action required communicated to GP within 24 hours Recognise/explore intentional and non-intentional non-adherence and liaise with primary care team.

Discharging from service Declines service or failure to respond Non compliant with treatment and full mental capacity Preference is expressed to attend GP for ongoing management Repeated DNAs When stable, and optimised on anti-heart failure medications Discharged patients can self refer if HF decompensates, and our advice/input is required NICE guidelines recommend heart failure register at surgery and 6 monthly follow ups.

Ivabradine SHIFT trial Reduces mortality/hospitalisation of symptomatic patients EF 35% or below, HR 75 bpm or above, on maximum tolerated BB Slows HR through inhibition of If channel in the sinus node Should only be used in SR.

When to use Ivabradine NYHA II to IV and LVEF 35% or less In SR, HR 75bpm or more despite treatment with beta blocker, or unable to tolerate/contraindicated Initiated by HF specialist with access to MDT HF team Dose 2.5mg to 7.5mg bd.

Sacubitril/Valsartan (Entresto) Paradigm-HF trial, reduction in all cause mortality and hospitalisation Sacubitril = Neprilysin Inhibitor (ARNI) Natriuretic peptides (A and B type) inhibit renin and aldosterone release Neprilysin degrades natriuretic peptides As Sacubitril inhibits Nelprilysin, levels of these peptides increase, resulting in diuresis, natriuresis, myocardial relaxation, vasodilation and reduced remodelling. Evidence from Paradigm-HF trial

When to use Entresto LVEF 35% or less Symtomatic despite taking stable dose ACEI or ARB (NTHA II-IV) Concomitant use of ACEI contraindicated, must be stopped and have 36 hr washout period prior to commencing Initiated under specialist guidance Dose 24/26mg, 49/51mg or 97/103mg, bd.

Cardiac resynchronisation therapy (CRT) LVEF 35% or less Treatment options depend on NYHA class, QRS duration and presence of LBBB LV electrical dyssynchrony contributes to cardiomyopathy and symptoms Synchronised biventricular pacing can lead to increased stroke volume, reverse remodelling.

HFpEF management No treatment has been shown convincingly to reduce morbidity or mortality Manage co-morbidities Diuretics usually improve symptoms Evidence for ARB/ACEI, MRA and BB to improve symptoms and mortality is lacking.

Thank you. Any questions?