1. Heart Failure 2014 Dr Maurice Pye Consultant Cardiologist
York District Hospital

2. 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

3. 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

4. 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

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

6. 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

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

8. Diagnosis
Diagnosis is difficult
Symptoms, signs and investigations

9. Symptoms in the diagnosis of heart failure
Symptom Sensitivity % Specificity %
Dyspnoea
Orthopnoea
PND
Oedema

10. Signs in the diagnosis of heart failure
Clinical findings Sensitivity Specificity
Raised JVP
Crackles
Gallop
Oedema

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

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

13. 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

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

15. 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

16. 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

17. 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

18. 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]

19. 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]

20. 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]

21. Caveats in role of ECHO -NICE
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]
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]
Ensure that those reporting echocardiography are experienced in doing so. [2003]

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

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

24. 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

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

26. 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-

27. NICE 2010 Heart Failure Key Implementation
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]

28. 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

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

31. 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

32. 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]

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

35. 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

36. Aldosterone Antagonist NICE 2010
Aldosterone antagonists (second-line treatment)
See also recommendations and
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]

37. Lives saved with Rx TRIAL Lives saved/1000/year HOPE <1 SOLVD-P 7
SOLVD-R
MERIT
CIBIS
RALES
COPERNICUS 70

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

44. 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

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

46. 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

47. 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

48. 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
ms, no LBBB
ICD
CRT-P
ms with LBBB
CRT-D
CRT-P/D
≥ 150ms

49. 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%)

50. 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

51. Combined Biventricular Pacemaker and ICD device

52. 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

53. 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+ )

54. 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

55. 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

56. 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