1. Advances in Heart Failure June 2012

2. Heart Failure – a Definition
“a complex clinical syndrome of symptoms and signs that suggest impairment of the heart as a pump supporting physiological circulation. It is caused by structural or functional abnormalities of the heart. The demonstration of objective evidence of these cardiac abnormalities is necessary for the diagnosis of heart failure to be made. The symptoms most commonly encountered are breathlessness (exertional dyspnoea, orthopnoea and paroxysmal nocturnal dyspnoea) fatigue and ankle swelling.”
NICE (2010)

3. The Heart

4. CO = SV x HR Pathophysiology
Cardiac Output = volume of blood pumped by the LV per minute.
Stroke Volume = volume ejected in one contraction
CO = SV x HR

5. Aortic & Peripheral Impedance
Pathophysiology
Venous Pressure
(LV preload)
Heart Rate
Cardiac Output
Aortic & Peripheral Impedance
(Afterload)
Myocardial
Contractility

6. Heart Failure Oedema Activation of sympathetic nervous system
Vasoconstriction/ ↑Afterload
Initially compensatory
↓Cardiac output
↓Renal perfusion
↑Preload
↓Tissue perfusion
Muscle fatigue/ lethargy
Renin release
↑Central venous pressure
Angiotensin Converting Enzyme (ACE)
Angiotensin I (ATI)
Pulmonary oedema.
Angiotensin II (ATII)
Aldosterone
Oedema
Sodium (Na+) and water retention

7. Diagnosis of heart failure
NICE (2010)

8. Advances in Heart Failure
● Brain Natriuretic Peptides
● Heart Failure With Preserved Ejection Fraction
● New Pharmacological Therapies
● Community IV Diuretic Therapy

9. Brain Natriuretic Peptide (BNP)
● 32 Amino acid polypeptide
● Released by ventricles in response ventricular wall stretch and damage to myocytes
● Initially found in porcine brain cells. In humans is found in cardiac ventricles
● Measured by blood test
● Positive levels may indicate heart failure and should prompt further investigation
● Normal levels can rule out heart failure
● Does not confirm Left Ventricular Systolic Dysfunction – BNP also released in right sided heart failure and diastolic heart failure
● BNP measurement can be used to monitor effects of treatment
● About to be launched in Nottingham

10. Causes for Raised BNP Cardiac ● Heart Failure
● Acute Coronary Syndrome
● Valvular Disease
● Left Ventricular Hypertrophy
● Atrial Fibrillation

11. Causes for Raised BNP Non-Cardiac ● Renal failure ● Pulmonary Embolism
● Pulmonary Hypertension
● Sepsis
● Chronic Obstructive Pulmonary Disease (with corpulmonale or respiratory failure)
● Hyperthyroid disorder

12. Heart failure with preserved ejection fraction (diastolic heart failure)
Often presumed when symptoms and signs of heart failure occur in a patient with preserved left ventricular systolic function (normal ejection fraction/normal end-diastolic volume) at rest
Characterised by prolonged LV relaxation; slow LV filling and increased LV and arterial stiffness.
More common in the elderly, women and those with hypertension or diabetes
Diagnosis and management remain controversial
Echocardiography may help confirm the diagnosis
Normal LV ejection fraction with atrial enlargement / dilatation and/ or left ventricular hypertrophy
Isolated diastolic dysfunction of the left ventricle may be the underlying cause of heart failure in a sizeable minority of patients with heart failure, particularly in the elderly.
A definitive diagnosis of isolated diastolic dysfunction can be made through cardiac catheterisation. There is no evidence that such investigation is justified for most patients with suspected heart failure, but it may be required in cases of serious diagnostic doubt.
Debate continues as to how best to confirm a diagnosis of ‘diastolic’ heart failure. In practice, the diagnosis is generally based on the findings of typical symptoms and signs of heart failure in a patient who is shown to have normal left ventricular systolic function and no valvular abnormalities on echocardiography. The diagnosis of such ‘diastolic’ heart failure is thus usually by exclusion of other cardiac abnormalities. Further research in this area is required. It is important that other conditions that may masquerade as heart failure are excluded. Normal natriuretic peptide concentrations in a untreated patient make the diagnosis unlikely.
Echocardiography may help confirm the diagnosis. Diagnosis requires three conditions to be satisfied:
Signs and/or symptoms of chronic HF
Normal or only mildly abnormal LV systolic function (LVEF ≥45-50%)
Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness)
Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. ESC guidelines for the diagnosis and treatment of chronic heart failure Eur Heart J 2008;29:
National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at and and on the website of the National Electronic Library for Health
(ESC, 2008; NICE, 2010) 12

13. Heart failure with preserved ejection fraction (diastolic heart failure)
Natriuretic peptides may be helpful in ruling out heart failure in those with preserved ejection fraction
Treatment:
ACE-Inhibitors
PEP-CHF Perindopril – No effect on Mortality or Hospital Admissions
Angiotensin Receptor Blockers
CHARM-Preserved Candesartan – No significant effect on cardiovascular death but there were fewer hospital admissions
I-Preserve Irbesartan – No effect on mortality or hospital admissions
Betablockers
OPTIMIZE-HF Registry – included both HFpEF and LVSD. Patients discharged on betablockers. No effects on clinical outcomes in HFpEF
Isolated diastolic dysfunction of the left ventricle may be the underlying cause of heart failure in a sizeable minority of patients with heart failure, particularly in the elderly.
A definitive diagnosis of isolated diastolic dysfunction can be made through cardiac catheterisation. There is no evidence that such investigation is justified for most patients with suspected heart failure, but it may be required in cases of serious diagnostic doubt.
Debate continues as to how best to confirm a diagnosis of ‘diastolic’ heart failure. In practice, the diagnosis is generally based on the findings of typical symptoms and signs of heart failure in a patient who is shown to have normal left ventricular systolic function and no valvular abnormalities on echocardiography. The diagnosis of such ‘diastolic’ heart failure is thus usually by exclusion of other cardiac abnormalities. Further research in this area is required. It is important that other conditions that may masquerade as heart failure are excluded. Normal natriuretic peptide concentrations in a untreated patient make the diagnosis unlikely.
Echocardiography may help confirm the diagnosis. Diagnosis requires three conditions to be satisfied:
Signs and/or symptoms of chronic HF
Normal or only mildly abnormal LV systolic function (LVEF ≥45-50%)
Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness)
Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. ESC guidelines for the diagnosis and treatment of chronic heart failure Eur Heart J 2008;29:
National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at and and on the website of the National Electronic Library for Health 13

14. Heart failure with preserved ejection fraction (diastolic heart failure)
Ongoing Research:
Phosphodiesterase 5 Inhibitors
Reduce ventricular-vascular stiffening
Improve endothelial function
Reduce pulmonary vascular stiffness
Sildenafil currently being tested
Aldosterone Antagonists
Reduce vascular stiffness
Spironolactone being tested
Isolated diastolic dysfunction of the left ventricle may be the underlying cause of heart failure in a sizeable minority of patients with heart failure, particularly in the elderly.
A definitive diagnosis of isolated diastolic dysfunction can be made through cardiac catheterisation. There is no evidence that such investigation is justified for most patients with suspected heart failure, but it may be required in cases of serious diagnostic doubt.
Debate continues as to how best to confirm a diagnosis of ‘diastolic’ heart failure. In practice, the diagnosis is generally based on the findings of typical symptoms and signs of heart failure in a patient who is shown to have normal left ventricular systolic function and no valvular abnormalities on echocardiography. The diagnosis of such ‘diastolic’ heart failure is thus usually by exclusion of other cardiac abnormalities. Further research in this area is required. It is important that other conditions that may masquerade as heart failure are excluded. Normal natriuretic peptide concentrations in a untreated patient make the diagnosis unlikely.
Echocardiography may help confirm the diagnosis. Diagnosis requires three conditions to be satisfied:
Signs and/or symptoms of chronic HF
Normal or only mildly abnormal LV systolic function (LVEF ≥45-50%)
Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness)
Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. ESC guidelines for the diagnosis and treatment of chronic heart failure Eur Heart J 2008;29:
National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at and and on the website of the National Electronic Library for Health 14

15. New Pharmacological Therapies
Eplerenone
Aldosterone Antagonist
Aldosterone contributes to vaso constriction and sodium and water retention
Previously used post myocardial infarction – reduced mortality if started within 30 days of MI in patients with LVEF <40% and clinical signs of heart failure (EPHESUS trial)
Isolated diastolic dysfunction of the left ventricle may be the underlying cause of heart failure in a sizeable minority of patients with heart failure, particularly in the elderly.
A definitive diagnosis of isolated diastolic dysfunction can be made through cardiac catheterisation. There is no evidence that such investigation is justified for most patients with suspected heart failure, but it may be required in cases of serious diagnostic doubt.
Debate continues as to how best to confirm a diagnosis of ‘diastolic’ heart failure. In practice, the diagnosis is generally based on the findings of typical symptoms and signs of heart failure in a patient who is shown to have normal left ventricular systolic function and no valvular abnormalities on echocardiography. The diagnosis of such ‘diastolic’ heart failure is thus usually by exclusion of other cardiac abnormalities. Further research in this area is required. It is important that other conditions that may masquerade as heart failure are excluded. Normal natriuretic peptide concentrations in a untreated patient make the diagnosis unlikely.
Echocardiography may help confirm the diagnosis. Diagnosis requires three conditions to be satisfied:
Signs and/or symptoms of chronic HF
Normal or only mildly abnormal LV systolic function (LVEF ≥45-50%)
Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness)
Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. ESC guidelines for the diagnosis and treatment of chronic heart failure Eur Heart J 2008;29:
National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at and and on the website of the National Electronic Library for Health 15

16. New Pharmacological Therapies
Now licensed in Chronic Heart Failure – Patients with LVEF <35% and NYHA 2. Eplerenone 25-50mg per day reduced cardiovascular mortality and hospital admissions (EMPHASIS trial)
Side effects:
As Spironolactone
Gynaecomastia less likely
Not on CityCare Formulary so needs to be prescribed by cardiologist
Isolated diastolic dysfunction of the left ventricle may be the underlying cause of heart failure in a sizeable minority of patients with heart failure, particularly in the elderly.
A definitive diagnosis of isolated diastolic dysfunction can be made through cardiac catheterisation. There is no evidence that such investigation is justified for most patients with suspected heart failure, but it may be required in cases of serious diagnostic doubt.
Debate continues as to how best to confirm a diagnosis of ‘diastolic’ heart failure. In practice, the diagnosis is generally based on the findings of typical symptoms and signs of heart failure in a patient who is shown to have normal left ventricular systolic function and no valvular abnormalities on echocardiography. The diagnosis of such ‘diastolic’ heart failure is thus usually by exclusion of other cardiac abnormalities. Further research in this area is required. It is important that other conditions that may masquerade as heart failure are excluded. Normal natriuretic peptide concentrations in a untreated patient make the diagnosis unlikely.
Echocardiography may help confirm the diagnosis. Diagnosis requires three conditions to be satisfied:
Signs and/or symptoms of chronic HF
Normal or only mildly abnormal LV systolic function (LVEF ≥45-50%)
Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness)
Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. ESC guidelines for the diagnosis and treatment of chronic heart failure Eur Heart J 2008;29:
National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at and and on the website of the National Electronic Library for Health 16

17. New Pharmacological Therapies
Ivabradine
Controls heart rate by inhibiting conduction through the If Channel in the sinus node cells
Isolated diastolic dysfunction of the left ventricle may be the underlying cause of heart failure in a sizeable minority of patients with heart failure, particularly in the elderly.
A definitive diagnosis of isolated diastolic dysfunction can be made through cardiac catheterisation. There is no evidence that such investigation is justified for most patients with suspected heart failure, but it may be required in cases of serious diagnostic doubt.
Debate continues as to how best to confirm a diagnosis of ‘diastolic’ heart failure. In practice, the diagnosis is generally based on the findings of typical symptoms and signs of heart failure in a patient who is shown to have normal left ventricular systolic function and no valvular abnormalities on echocardiography. The diagnosis of such ‘diastolic’ heart failure is thus usually by exclusion of other cardiac abnormalities. Further research in this area is required. It is important that other conditions that may masquerade as heart failure are excluded. Normal natriuretic peptide concentrations in a untreated patient make the diagnosis unlikely.
Echocardiography may help confirm the diagnosis. Diagnosis requires three conditions to be satisfied:
Signs and/or symptoms of chronic HF
Normal or only mildly abnormal LV systolic function (LVEF ≥45-50%)
Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness)
Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. ESC guidelines for the diagnosis and treatment of chronic heart failure Eur Heart J 2008;29:
National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at and and on the website of the National Electronic Library for Health 17

18. New Pharmacological Therapies
Raised resting heart rate is a known risk factor for mortality and cardiovascular outcomes
In coronary artery disease and LV dysfunction a heart rate >70bpm increased risk of cardiovascular death by 34% and hospitalisation by 53%
Ivabradine can be used in addition to betablockade
No effect on Blood Pressure and safe in asthma so can be used as alternative to betablockade
Risk of cardiovascular death and hospital admission due to heart failure fell by 18% in heart failure patients treated with Ivabradine Vs Placebo – (SHIFT trial)
Isolated diastolic dysfunction of the left ventricle may be the underlying cause of heart failure in a sizeable minority of patients with heart failure, particularly in the elderly.
A definitive diagnosis of isolated diastolic dysfunction can be made through cardiac catheterisation. There is no evidence that such investigation is justified for most patients with suspected heart failure, but it may be required in cases of serious diagnostic doubt.
Debate continues as to how best to confirm a diagnosis of ‘diastolic’ heart failure. In practice, the diagnosis is generally based on the findings of typical symptoms and signs of heart failure in a patient who is shown to have normal left ventricular systolic function and no valvular abnormalities on echocardiography. The diagnosis of such ‘diastolic’ heart failure is thus usually by exclusion of other cardiac abnormalities. Further research in this area is required. It is important that other conditions that may masquerade as heart failure are excluded. Normal natriuretic peptide concentrations in a untreated patient make the diagnosis unlikely.
Echocardiography may help confirm the diagnosis. Diagnosis requires three conditions to be satisfied:
Signs and/or symptoms of chronic HF
Normal or only mildly abnormal LV systolic function (LVEF ≥45-50%)
Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness)
Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. ESC guidelines for the diagnosis and treatment of chronic heart failure Eur Heart J 2008;29:
National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at and and on the website of the National Electronic Library for Health 18

19. New Pharmacological Therapies
Does not work in AF
Start at 5mg BD and titrate to 7.5mg BD
Side effects:
Visual disturbance (phosphenes)
Bradycardia
Previously used in angina. Now licensed in heart failure
Not on CityCare formulary so prescribed by cardiologist
Isolated diastolic dysfunction of the left ventricle may be the underlying cause of heart failure in a sizeable minority of patients with heart failure, particularly in the elderly.
A definitive diagnosis of isolated diastolic dysfunction can be made through cardiac catheterisation. There is no evidence that such investigation is justified for most patients with suspected heart failure, but it may be required in cases of serious diagnostic doubt.
Debate continues as to how best to confirm a diagnosis of ‘diastolic’ heart failure. In practice, the diagnosis is generally based on the findings of typical symptoms and signs of heart failure in a patient who is shown to have normal left ventricular systolic function and no valvular abnormalities on echocardiography. The diagnosis of such ‘diastolic’ heart failure is thus usually by exclusion of other cardiac abnormalities. Further research in this area is required. It is important that other conditions that may masquerade as heart failure are excluded. Normal natriuretic peptide concentrations in a untreated patient make the diagnosis unlikely.
Echocardiography may help confirm the diagnosis. Diagnosis requires three conditions to be satisfied:
Signs and/or symptoms of chronic HF
Normal or only mildly abnormal LV systolic function (LVEF ≥45-50%)
Evidence of diastolic dysfunction (abnormal LV relaxation or diastolic stiffness)
Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. ESC guidelines for the diagnosis and treatment of chronic heart failure Eur Heart J 2008;29:
National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Available at and and on the website of the National Electronic Library for Health 19

20. Community IV Diuretics
Pilot project in Nottingham CityCare
BHF funded (18.75 hours p/w band 6 nurse)
Supported by Cardiologist
13 pilot sites in the UK
2 years pilot with external evaluation
Nottingham CityCare and Nottingham West Consortia are “Case Study” sites

21. Evidence
Nurse led community heart failure follow up reduces hospital admissions (Blue et al, 2001)
IV diuretics in an outpatient setting in selected patients is safe, feasible, clinically effective and avoids hospital admissions (Ryder et al, 2008)
A nurse led IV antibiotic and IV iron service in Cheshire saved £1m over three years (Lomas, 2009)

22. Patient Selection 1. Inclusion criteria:
Known LVSD and on HFSN Caseload
Mental capacity to understand and agree to treatment
Carer support
Optimised oral diuretic therapy
Increased symptoms of breathless; oedema; weight gain; PND; ascites etc

23. Patient Selection 2. Inclusion criteria: Systolic BP>90mmHg
O2 saturation >90%
U+E – NA+ >128 mmols/L; K+ >3.5 mmols/L; Creatinine <250 µmols/L; eGFR >30mls/min
Hb >9.0 g/dL
Otherwise clinically stable
End of Life care / palliative

24. Patient Selection 3. Exclusion criteria: No confirmation of LVSD
Not known to HFSN
Acute or severe renal failure (CKD 4-5)
Limited mental capacity – unable to understand or agree to treatment
Poor social support

25. Patient Selection 4. Exclusion criteria: Severe Aortic Stenosis
Other conditions requiring acute management
Unable or unwilling to carry out self management (daily weight; fluid balance; fluid restriction)
In End of Life Care IV diuretic may be given despite clinical parametres if agreed with GP, consultant and patient

26. Before IV Diuretics
Patient selection – decompensated heart failure symptoms despite optimised oral therapy; fulfils inclusion criteria
Discussion with patient; carer; GP; Consultant
Preparation
Education
Informed consent
Cannulation
Equipment

27. Delivering IV Diuretics
Drug Administration
McKinley T34 Syringe Driver
Furosemide for injection / infusion
4mg /min
Daily Monitoring
Fluid balance; weight; oedema; symptoms; VIP score
BP; HR; O2 saturation; ?use of Telehealth
U+E (blood taken 4 hours post administration)

28. Dosage Schedule Day 1 Administer IV Furosemide 40mg daily Day 2
If diuresis of 1-2 litres or weight loss of 1-2kg (over last 24 hours) continue IV furosemide 40mg daily
If diuresis of <1 litre or weight loss of <1kg (over last 24 hours) increase IV Furosemide to 80mg daily
If diuresis of >2 litres or weight loss of >2kg, consider reducing IV Furosemide to 20mg daily
Day 3-4
If diuresis of 1-2 litres or weight loss of 1-2kg (over last 24 hours) continue IV Furosemide 80mg daily
If diuresis of <1 litre or weight loss <1kg (over last 24 hours) consider increasing IV Furosemide by 40mg per day (to a maximum of 160mg daily in two doses of 80mg).
If diuresis of >2 litres or weight loss of >2kgs, reduce dose by 40mg
Day 4-5 onwards
If inadequate response to treatment despite increased doses of IV Furosemide, or if unable to titrate due to clinical findings, discuss with GP / consultant / Cardiology Registrar with a view to hospital admission.
If good response to treatment, continue dose schedule and / or discontinue IV Furosemide when treatment goals are achieved.

29. Withdrawal of IV Diuretics
Treatment has been effective
Treatment is not effective after 3 days (?hospital admission / cardiology review)
Patient chooses to withdraw
Adverse reactions occur
Clinical parametres indicate IV Diuretics should not be continued
If treatment effective, IV diuretics are stopped and normal oral dosing resumes

30. Evaluation of IV Diuretics at Home
Is it safe?
What doses are safe and effective?
Effect on hospital admissions?
Patient and carer experience.
Is it cost effective?
Is it sustainable
Impact on HF service?
Impact on other services (NEMS; DN; GP)?

31. What next? Dissemination of IV Diuretics Procedure
Final sign off of all documentation
Development of IV Policy
Cannulation competence
Patient Recruitment
Ongoing training

32. Any Questions?

33. Contact information:
Office:
Fax:
New Brook House
385 Alfreton Road
Radford, NG7 5LR