Heart Failure 2014 Dr Maurice Pye Consultant Cardiologist York District Hospital

Heart Failure 2014 Introduction – numbers – prevalence prognosis NICE Guidelines – 2010 including recent 2014 guidance on complex devices Discuss DIAGNOSIS Go over management Role of Secondary Care

Heart Failure: The Problem 1 Prevalence 3-20/1000 of the population (80/1000 in 75+) Incidence 1/1000 population per year (10/1000 per year 85+) Median 76 years Average GP will have 30 pts with HF and suspect new diagnosis in 10/yr

Heart Failure: The Problem 2 5% of all hospital acute admissions (50% readmitted within 3/12) and 2% of all hospital bed IP days Expected to rise 50% over next 20 years due to aging pop 2-3 visits to the GP per year 1/3 have prolonged/severe depression Annual mortality 30-40% in 1 st year then ~ 10% yr 5yr survival in GP registries = 58% compared to 93% for age/sex matched population

Heart Failure: Aetiology What are the causes of heart failure ?

Heart Failure: Aetiology Ischaemic heart disease Hypertension (LVH  risk 15x) Cardiomyopathy: Alcohol, genetic, chemotherapy – anthracyclines and herceptin Valvular heart disease Arrhythmias – tachycardiomyopathy – particularly prolonged silent AFib Pericardial disease – mimics --- Normal echo, signs of right heart failure – but no intrinsic lung disease and normal CXR

How do you diagnose heart failure? Diagnosis How do you diagnose heart failure?

Diagnosis Diagnosis is difficult Symptoms, signs and investigations

Symptoms in the diagnosis of heart failure Symptom Sensitivity % Specificity % Dyspnoea 66 52 Orthopnoea 21 81 PND 33 76 Oedema 23 80

Signs in the diagnosis of heart failure Clinical findings Sensitivity Specificity Raised JVP 17 98 Crackles 29 77 Gallop 24 99 Oedema 20 80

Investigations in the diagnosis of HF: ECG Ability of a normal ECG to exclude LV systolic dysfunction Sensitivity 94% Specificity 61% PPV 35% NPV 98% (However one report: 27% poor LV had N ECG)

CXR in the diagnosis of heart failure: Cardiothoracic ratio > 50% is specific, not sensitive Useful to exclude other causes of SOB

ECHO in the diagnosis of heart failure: ‘Best test’ for assessment LV systolic dysfunction Of those on HF treatment only 25% have significant LV Only 25% referred from 1o care have LV systolic dysfunction Only 8% ? New heart failure had LV systolic dysfunction ?Diastolic dysfunction and heart failure

BNP and the diagnosis of heart failure BNP as a screening tool for HF in 1o care Sensitivity 76 / 97% Specificity 84 / 87% PPV 70 / 16% NPV 98 / 98%

BNP /NT proBNP levels + with age or female - with obesity + in CKD + in raised pulmonary artery pressure COPD, PE, cor pulmonale + in AF + in valvular heart disease – MR , AS, MS + in sepsis + in pericardial disease

BNP in LVF some caveats Atrial fibrillation associated with higher BNP values so higher cut off = 200pg/ml increased specificity from 40 to 73% with redn in sensitivity from 95 to 85% Adding BNP to clinical judgement in ER increased diagnostic accuracy from 70 to 80% BNP correctly picked up more than 90% of patients thought to have low clinical probability of LVF

BNP caveats Most dyspnoeic patients with HF have values above 400 while values below 100 have a very high negative predictive value for HF as a cause of dyspnea In the range between 100 and 400 plasma BNP concentrations can have lowe sensitivity or specificity for detecting or excluding HF

NICE 2010 HF Diagnosis Key Implementations 1 Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks. [new 2010] A BNP level above 400 pg/ml (116 pmol/litre) or an NTproBNP level above 2000 pg/ml (236 pmol/litre) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks. [new 2010]

NICE 2010 HF Diagnosis Key Implementations 2 Refer patients with suspected heart failure and a BNP level between 100 and 400 pg/ml (29–116 pmol/litre) or an NTproBNP level between 400 and 2000 pg/ml (47–236 pmol/litre) to have transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks. [new 2010]

NICE 2010 HF Diagnosis Key Implementations 3 a serum BNP level less than 100 pg/ml (29 pmol/litre) or an NTproBNP level less than 400 pg/ml (47 pmol/litre) in an untreated patient makes a diagnosis of heart failure unlikely the level of serum natriuretic peptide does not differentiate between heart failure due to left ventricular systolic dysfunction and heart failure with preserved left ventricular ejection fraction. [new 2010]

Caveats in role of ECHO -NICE 1.1.1.7 Perform transthoracic Doppler 2D echocardiography to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts. [2003] 1.1.1.8 Transthoracic Doppler 2D echocardiography should be performed on high-resolution equipment, by experienced operators trained to the relevant professional standards. Need and demand for these studies should not compromise quality. [2003] 1.1.1.9 Ensure that those reporting echocardiography are experienced in doing so. [2003]

Treatment of heart failure General measures Drug therapy All major trials Rx LV systolic dysfunction

General measures for heart failure Other than drugs what do you advise/consider for your HF patients ?

General measures for heart failure Risk factor management Smoking, obesity, lipids, HT, DM, Alcohol Salt reduction( 3g/day) ?? Avoid Calcium antagonists, NSAIDs, Anti-arrhythmics Other Flu vacc, Pneumococcal vacc, OPD/HOME F/U Exercise programme Selected patients Control AF, anticoagulation, revascularization

Drug treatment for heart failure Which agents prolong life? Which agents do you use?

Drug treatment for heart failure Diuretics ACE inhibitors Beta blockers Spironolactone Angiotensin II receptor blockers (ARBs) (sartans) Digoxin AF +- sinus rhythm Hydralazine and nitrates (if ACE or sartans not tolerated) Warfarin NEW PARADIGM TRIAL – ACE- neprolysin-

NICE 2010 Heart Failure Key Implementation 1.2.2.2 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]

ACE I/ARB: How to do it WHO WHEN HOW All patients with HF Care: K+ > 5.5 or Cr >200 or Ur >12 or Na 130 or SBP < 100 or > frusemide 80 mg od WHEN Once HF confirmed (Ideally echo LV function) HOW Stop K+ supp and NSAID and warn re hypotension U&E’s/K+ week 1 and 4 and ? 6 monthly after Low dosemid 1/52. Target dose 1/12 Refer if adverse effects as above

NICE 2010 ACE inhibitors ACE inhibitors (first-line treatment) 1.2.2.5 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] 1.2.2.6 Measure serum urea, creatinine, electrolytes and eGFR at initiation of an ACE inhibitor and after each dose increment[2010]

Beta-blockers: How to do it WHO: For all with mild/moderate HF (NYHA II/III) HR>60 SBP>100 Clinically stable >4/52, no AMI/UA >3/12 WHEN Once Euvolaemic HOW Bisoprolol 1.25 (1/52) 2.5(1/52)3.75(1/52) 5 (4/52) 7.5 (4/52) 10 mg

NICE guidance Beta blockers 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]

NICE guidance Beta blockers 1.2.2.8 Introduce beta-blockers in a 'start low, go slow' manner, and assess heart rate, blood pressure, and clinical status after each titration. [2010] 1.2.2.9 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]

Spironolactone: How to do it WHO All patients with moderate/severe HF Care K+ > 5.0 or Cr >221 WHEN Once stabilized on ACE I HOW Dose 25 mg/day U&E’s/K+ week 1 and 4 and ? 3-6 monthly after

Aldosterone Antagonist NICE 2010 Aldosterone antagonists (second-line treatment) See also recommendations 1.2.2.3 and 1.2.2.4. 1.2.2.10 In patients with heart failure due to left ventricular systolic dysfunction who are taking aldosterone antagonists, closely monitor potassium and creatinine levels, and eGFR. Seek specialist advice if the patient develops hyperkalaemia or renal function deteriorates[22]. [new 2010]

Lives saved with Rx TRIAL Lives saved/1000/year HOPE <1 SOLVD-P 7 SOLVD-R 17 MERIT 38 CIBIS 42 RALES 52 COPERNICUS 70

Heart failure - whats on the horizon New Ace inhibitor Neprolysin inhibitor PARADIGM HF study ECS 2014

Previous Guidance TA95 2006 For Complex devices CRT or ICD ICD if; LVEF <35%, NSVT on Holter AND positive V-STIM OR LVEF <30% QRS >120ms No worse than NYHA 3 High risk condition Secondary prevention

Previous Guidance TA120 2007 CRT if NYHA 3 or 4 Sinus Rhythm Optimal medical Rx QRS > 150ms OR 120-149ms with echo dyssynchrony EF <35%

More Data since 2007 ICD No benefit early post MI DEBUT 2003 DINAMIT 2004 SCD-HeFT 2005 IRIS 2009 No benefit early post MI Benefit in non - ischaemic cardiomyopathy

More Data CRT RETHINQ 2007 PROSPECT 2008 REVERSE 2008 MADIT CRT 2009 RAFT 2010 ECHO-CRT 2013 Lack of benefit (harm) in normal QRS, benefit in NYHA 1 and 2 Echo dyssynchrony assessment unhelpful

NICE GUIDANCE 2014 ANY HEART FAILURE, LVEF ≤ 35% QRS duration NYHA 1 NYHA2 NYHA3 NYHA4 <120ms ICD IF THERE IS A HIGH RISK OF SCD NO DEVICE 120-149ms, no LBBB ICD CRT-P 120-149ms with LBBB CRT-D CRT-P/D ≥ 150ms

ICD indications in 2014 Non – ischaemic cardiomyopathy NSVT / VT STIM no longer criteria ICD for high risk with normal QRS duration EF < 35% (rather than 30%)

ICDs, Biventricular Pacemakers and Combined CRT-D Given NICE guidance and based on contemporary evidence there are going to be a lot more complex devices implanted into patients with HF due to LV systolic dysfunction Estimates of increase of 2x more patients receiving devices Who is going to pay? – at present Specialist Commissioning Group – but they are trying to pass back to CCG

Combined Biventricular Pacemaker and ICD device

Suspected Heart Failure-what to do in general practice 2014 If previous MI refer urgently to cardiologist Check BNP - If severely elevated REFER urgently for an echocardiogram and cardiology opinion If moderately elevated refer for cardiology opinion within 6 weeks

Suspected Heart Failure-what to do in general practice 2014 Baseline investigations (FBC,U+E Cr,T4) Start diuretics (frusemide) + non pharmacological Rx **Anticoagulate with warfarin if in Afib **If echo confirms then Rx with ACE- 1st and then a few weeks later betablockers = start low/go slow. **Consider spironolactone (monitoring K+ )

Heart Failure-what a cardiologist can do? Confirm diagnosis in borderline cases Consider other diagnoses Investigate underlying cause – especially if there is any revascularisation or valve lesion issue Assess 24 hr heart rate in Afib Assess for DEVICE THERAPY

NICE guidance 2010 1.5.1 Referral for more specialist advice the initial diagnosis of heart failure – valvular heart disease, need for revascularisation, dysrhythmias Consideration of Device Therapy ** The management of: severe heart failure (NYHA class IV)& that does not respond to treatment heart failure that can no longer be managed effectively in the home setting. [new 2010] **- Dr Pye’s addition 2014

Summary HF is increasingly prevalent. Diagnosis is problematic use BNP and Echo. Strong evidence base for the treatment of HF (ACE I, BB, SPIRO). New Drug – ACE receptor blocker and neprolysin - ARB, & Digoxin cautiously. Increasing use of Complex Device therapy. Need more Community heart failure nurses – just appointed a hospital based specialist nurse in HF – to improve discharge and reduce readmission