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

2. 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).

3. 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

4. Diagnostic pathway
Recorded prevalence of HF in London %, 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).

5. 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
ng/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.

6. 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

7. 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.

8. 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.

9. 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.

10. 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).

11. 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.

12. 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.

13. 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.

15. 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.

16. 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.

17. 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

18. 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.

19. 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.

22. 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.

23. Thank you. Any questions?