2. Heart Failure Hazel Phillips Cardiac Support Nurse Bedford Hospital NHS Trust

3. Heart Failure “Complex clinical syndrome that impairs the ability of the heart to respond to physiological demands for an increased output” ( Sign 2007) “ It is recognised to be a chronic disease with poor outcomes worse than many cancers” ( Cowie & Zaphirious, 2004)

4. Causes of Heart Failure Coronary Heart Disease (MI ) Hypertension Valvular heart disease (Aortic and Mitral valve) Cardiac arrhythmias (heart block atrial fibrillation Cardiomyopathy (dilated, hypertrophic alcoholic,& idiophatic

5. Symptoms of Heart Failure Shortness of breath Fatigue Proximal Nocturnal Dyspnoea Increase in weight Peripheral oedema Anorexia Orthopnoea  Nocturnal cough

7. Diagnosis Full medical history and examination ECG Blood screen & BNP(Brain natriuretic peptide ) best taken off diuretic therapy If BNP positive request referral to H F clinic

8. Heart Failure Clinic Bloods for U&E, TFT, LFT, Glucose, Lipid profile, Full blood count Chest X-ray ECG Echo (Gold standard) Full examination Diagnosis and Medical plan given

9. Echocardiogram Developed 50 yrs ago Elder & Herz Ultrasonic waves are used to investigate and display the action of the heart as it beats. Non invasive test,painless, safe Examines size, function, and blood flow through the heart

10. LV Ejection Fraction LV ejection fraction Qualitative assessment >75%Hyper-dynamic 55-75%Normal 40-54%Mildly 30-39%Moderate <30% Severe

14. NYHA Classification Class I No Limitation on activity Annual Mortality No fatigue, breathlessness, palpitations 3%-5% on ordinary physical activity Class II Pt are comfortable at rest but physical activity such as climbing stairs results in 10% symptoms Class III Pt have marked limitations on physical activity, but comfortable at rest 12%-15%. Class IV Pt have symptoms at rest and any activity results in discomfort 15% - 20% worse prognosis than some cancers

15. Medication Loop Diuretic Furosemide, Bumetanide Use lowest dose to reduce fluid overload, Side effects hypotension (causing dizziness, light-headedness, or confusion) and hypokalemia. Regular checks of U&E

16. Diuretics Metolazone Used for intractable oedema Use with close monitoring of renal function Can cause hyponatraemia Profound diuresis when used with loop diuretics

17. Beta-blockers Increase life expectancy Contra indicated in Asthma and COPD Pt should be stable not fluid overloaded Start low and increase slowly Licensed for HF Carvedilol 3.12mg- 25mg BD, Bisoprolol 1.25mg-10mg OD, or Nebivolol 1.25mg-10mg OD

18. Beta-Blockers May worsen HF symptoms Monitor BP & pulse rate Side effects hypotension, bradycardia, cold extremities (causing paraesthesia), sleep disturbances (including nightmares), and sexual dysfunction

19. Angiotensin-Converting Enzyme (ACE) inhibitor Improves symptoms and life expectancy Base line U&E’s Start low and increase slowly Lisinopril 2.5mg –30mg OD Ramipril 2.5mg – 10mg OD Enalapril 5mg –10mg OD Warn pt of first dose hypotension

20. ACE Inhibitors Monitor Creatinne & Potassium levels Side effects Hypotension, Cough, rash, tiredness etc If cough troublesome can swap to a angiotensin II receptor antagonists (ARB) ie. Losartan, candesartan

21. Aldosterone Antagonist Moderate to severe HF NYHA Class III – IV symptomatic on usual therapy Reduces mortality Spironolactone 25mg only drug licensed Eplerenone only licensed for LVF post MI Monitor U&E Potassium sparing diuretics

22. Aldosterone Antagonist Side effect: gastro-intestinal disturbances impotence, gynaecomastia, lethargy, headache etc

23. Digoxin Used if pt has an arrhythmia ie AF Can be used as last “resort” if all other medication have not improved symptoms Monitor for side effect and toxicity.

24. Contraindicated Medication NSAID Calcium Channel Blocker(except amlodipine & diltiazem) Metformin Glitazones Corticosteriods Tricylic antidepressants

25. Non-Pharmacological Advice Self management of condition Monitor weight daily Avoid salty food & “lo salt”replacement products Influenza & Pneumococcoal vaccinations Lifestyle advice Exercise advice/ Cardiac rehabilitation Six monthly review

26. Cardiac Cachexia Complication of end stage HF Loss of muscle mass & adipose tissue Resulting in reduced exercise tolerance,fatigue and dyspnoea Ensure adequate nutrition supplements Advice from dieticians

27. Other treatment options Dual chamber pacemakers + ICD Revascularisation (CABG PCI) Transplantation Left ventricular assist devices (LVAD) Palliative care

28. Further Information National Service Frame work (2000) Chapter six Heart failure NICE Clinical Guideline 5 (2003) Management of chronic heart failure in adults in primary and secondary care Modernisation Agency (2004) Supportive and palliative care for advanced heart failure

29. Further information Scottish Intercollegiate Guidelines Network (Sign) 2007 Management of Chronic Heart Failure

31. Any Questions