an introduction to heart failure management hayley pryse-hawkins heart failure nurse royal brompton hospital 020 735

1. An Introduction to Heart failure managementHayley Pryse-Hawkins Heart Failure NurseRoyal Brompton Hospital020 73518744

3. Definition Heart failure has been defined as a �syndrome which develops as a consequence of cardiac disease and is recognised clinically by a constellation of symptoms and signs produced by complex circulatory and neurohormonal responses to cardiac dysfunction�.

4. More definitions!

5. ESC definition: Acute Heart Failure The rapid onset of symptoms and signs secondary to abnormal cardiac function�.with or without previous cardiac disease The cardiac dysfunction can be related to systolic or diastolic dysfunction, to abnormalities in cardiac rhythm, or to preload and afterload mismatch. AHF can present as: acute de novo, or acute decompensation of chronic heart failure

6. Symptoms consistent with heart failure: dyspnoea, fluid retention, effort intolerance Evidence of fluid retention: Peripheral oedema and raised JVP, or chest radiograph showing pulmonary oedema or effusions Clinical evidence (including echocardiography) of cardiac dysfunction Wherever possible, response to appropriate therapy for heart failure ESC definition: Chronic Heart Failure

8. Aetiology of heart failureBromley Heart Failure Study: 136 cases aged < 75

9. Burden of heart failure 63,000 new cases each year in the UK 878,000 people suffer from definite or probable heart failure at any one time 40% of people will die within one year Causes 5% of all deaths One million bed days (2% of total) Admissions projected to rise by 2% per year

11. The cost of heart failure is driven by inpatient care Heart failure is a very expensive condition � the estimated total annual cost to the NHS is �625 million per year, or around 1.8% of the NHS budget. The cost of managing heart failure is largely driven by inpatient care costs. In England, heart failure currently accounts for around one million inpatient bed days, and this constitutes around 60% of the estimated �625 million annual cost of heart failure. In addition, patients have frequent contact with primary care, requiring on average 11-13 contacts per year with the GP or other members of the primary care team. By contrast, drug costs in heart failure account for a very small proportion of the total cost of care, around 9%. The burden of heart failure is expected to grow over the next 20 or 30 years: hospital admissions for heart failure are expected to rise by 50% over the next 25 years. Petersen S, Rayner M, Wolstenholme J. Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation, 2002. Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 2002; 105: 2861?6. Heart failure is a very expensive condition � the estimated total annual cost to the NHS is �625 million per year, or around 1.8% of the NHS budget. The cost of managing heart failure is largely driven by inpatient care costs. In England, heart failure currently accounts for around one million inpatient bed days, and this constitutes around 60% of the estimated �625 million annual cost of heart failure. In addition, patients have frequent contact with primary care, requiring on average 11-13 contacts per year with the GP or other members of the primary care team. By contrast, drug costs in heart failure account for a very small proportion of the total cost of care, around 9%. The burden of heart failure is expected to grow over the next 20 or 30 years: hospital admissions for heart failure are expected to rise by 50% over the next 25 years. Petersen S, Rayner M, Wolstenholme J. Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation, 2002. Stewart S, Horowitz JD. Home-based intervention in congestive heart failure: long-term implications on readmission and survival. Circulation 2002; 105: 2861?6.

14. People with heart failure have impaired quality of life as a result of : physical symptoms adverse effects of treatment psychological problems social limitations Quality of life is directly linked to functional ability in these patients.

15. Symptoms Breathlessness Effort intolerance Fluid retention orthopnoea PND Palpitations syncope Fatigue

17. AHF Treatment Telemetry Sit upright High flow O2 Diamorphine 2.5-5mg IV nitrate GTN 1-2mg/hr (If BP will tolerate) IV frusemide Consider NI ventilation Consider inotropes Goals of treatment Stabilise physiology Relieve symptoms Look for underlying cause

18. Management algorithm for HF Establish patient has HF Identify aetiology of HF Identify concomitant disease relevant to HF Assess severity of symptoms Assess prognosis Anticipate problems Choose and tailor treatment Follow up and modify treatment

19. Principles of drug management Evidence based Aims � mortality / morbidity Simple Patient engagement Routine Optimisation Cautions

20. Diuretics Loop diuretics, thiazide diuretics, potassium-sparing, Symptom management Monitoring � fluid status, U&Es, symptoms Patient control Problem solving

21. Ace Inhibitors LV dysfunction � research Titrate to optimum dose Monitor � BP + U&Es (potential side-effects) Patient advise Problem solving

22. Angiotensin Receptor Blockers LV dysfunction � intolerant of ACE 1 CHARM Monitor Patient advise Problem solving

23. Beta Blockers Stable Heart Failure, on an ACE 1 / ARB �Start slow, go slow� Monitoring Patient education and engagement Problem solving

24. Aldosterone antagonists Symtoms despite optimised therapy in LV dysfunction / LV dysfunction post MI Monitoring Problem solving

25. Digoxin Worsening/severe H.F. despite optimized therapy in LV dysfunction Morbidity not mortality � reduce admissions Management of AF Monitoring

26. Nitrates Management of angina Vasodilatation Monitoring and review (ACE 1 intolerant/contraindicated � with hydralazine) Patient education

27. Symptom management Analgesics Anti-emetics Sedation Depression & anxiety Breathless management Aperients

28. Co morbidities Arrhythmic management Arthritis Warfarin Statins Diabetes

29. Cautionary medication NSAIDs Calcium Channel Blockers � except Amlodipine Herbal medication � cod liver oil,

30. Importance of drug compliance Who can modify medications Blood tests / Eye tests etc � amiodarone Review Tools

31. Patients understanding of heart failure 1.Inadequate knowledge of causes symptoms and consequences Did not connect symptoms to CHF Did not distinguish acute and chronic aspects of CHF 2.Did not see CHF as chronic disorder due to weak heart 3.Unable to recognise and address worsening symptoms Did not see link between swollen ankles and CHF Did not link action to symptoms

32. Mood in Heart Failure Depression Prevalence ranged between 15%-51% (Freedland et al. 2003) Anxiety Poor Data on Prevalence Levels of psychopathology significantly higher in heart failure than healthy population Levels of depression vary, dependent on measurement, regardless known that higher than in age adjusted healthy populationLevels of depression vary, dependent on measurement, regardless known that higher than in age adjusted healthy population

33. Interventions for Mood Cognitive Behaviour Therapy Problem Solving Interventions Anti-Depressant Therapy Typically Individual Based

38. Illness Adjustment in Heart Failure The extent that an individual acknowledges and manages their illness to maximise physical, social and emotional functioning and hence optimise quality of life Indicated by level of functioning, particularly social and emotionalIndicated by level of functioning, particularly social and emotional

39. Illness Adjustment in Heart Failure Cont. Important Predictors: Illness Cognitions (Time period, consequences, causes, symptoms, control) Coping Strategies (Information seeking, reinterpretation, denial, seeking support, wish fulfillment, emotional expression) Social Support

40. Adjustment Interventions to Improve Adjustment In Heart Failure: Non- Adherence: Information is necessary but not sufficient Illness Cognitions Barriers to Change Expectancies Self-Efficacy Adherence vs Self-Management

41. Coping Strategies: Interventions to Improve Self-Management

42. Education and information What heart failure is Diet Weight management Fluid status/balance Smoking Exercise Activity Prognosis Health care status Energy conservation Breathing Drug therapy Immunisation Healthy living Alcohol Stress management Relaxation Effects and management

43. Living with heart failure Positive Realistic Control Adaptation Expectations Fear Support

44. Effects of deconditioning in heart failure: Cardiac abnormalities Ventilatory abnormalities Abnormality of autonomic control Other effects � social and psychological Benefits of exercise: Improvement in Skeletal Muscles� Cardiac/Vasculature improvements Ventilatory Improvements Improvements in Autonomic control Psychosocial improvements

45. Illness Adjustment in Heart Failure The extent that an individual acknowledges and manages their illness to maximise physical, social and emotional functioning and hence optimise quality of life

46. Limiting effects of heart failure Reduced cardiac function / output Muscle weakness, cachexia, wasting Fatigue, lethargy Impaired cognitive function Altered mood Respiratory function

47. Rehabilitation & exercise Energy conservation Pacing Effects of deconditioning Benefits Function Safety

48. Benefits of Exercise: Studies have shown many benefits of exercise in CHF patients. Some of these are: Improvement in Skeletal Muscles� Cardiac/Vasculature improvements Ventilatory Improvements Improvements in Autonomic control Psychosocial improvements � Single muscle resistance training can have a positive effect in the untrained contralateral limb 30. � Symptomatic improvement in CHF patients depends on resolution of muscle abnormality 28. Even a small increase in exercise tolerance can dramatically reduce patients dependence thus making exercise therapy a cost-effective option of treatment8. �

49. Benefits of exercise: An improvement in: Skeletal Muscles� Cardiac/Vasculature Ventilatory Improvements Autonomic control Exercise also has an impact on a persons psychosocial staus Improvements can be achieved with modest �increase in exercise tolerance

50. Energy Conservation Definition: making the most of the body�s available energy and getting the most amount of work done using the least amount of energy 3 strategies: Pacing Co-ordinating breathing with daily activities Work simplification Application to daily activities

51. Pacing ��. �Rest before you get tired.� Benefits: Manageable breathing Stay active every day Good balance between activity and rest

52. Work simplification �Make the activities that need to be done during the day easier to do.� Plan Prioritise Good posture Organise the environment Assistive equipment

53. Breathing Use pursed lip and abdominal breathing Do not hold breath during activities! Exhale during the most strenuous part of the activity and when bending the trunk Inhale when lifting the arms up and when moving the arms away from the body Adequate ventilation

54. Cachexia Caused by prolonged cardiac insufficiency and heart failure Results in loss of muscle mass (Including cardiac muscle) and adipose tissue (fat mass) Affects symptoms and exercise capacity Features of malnutrition and Cachexia Progressive weight loss Poor immune response oedema Reduced tolerance to medical treatment Increased risk of complications Depression Untimely death

55. Balance of good health model

58. It is important the exercise is frequent (3x week) and manageable outside a supervised environment needs to fit into peoples lifestyle needs to continue needs to be regular needs to meet their needs

60. NICE Guidelines �Good communication between healthcare professionals...� Liaison Chronic disease management strategies Multi-disciplinary working Role model Education and resource �Your healthcare team should be listening to your feelings, fears, views and beliefs.� Knowledge Confidence Support Skills rehabilitation Palliation

61. NSF / NICE The NSF in CHD states that all patients diagnosed with heart failure should be offered treatments most likely to both relieve their symptoms and reduce their risk of death. NICE (2003) also advocate the use of exercise as being both safe and effective in patients with CHF though offer little advice on implementation. There is no single baseline factor that can be significantly correlated to outcome so it is not possible which patients may benefit most from exercise programmes from their clinical characteristics prior to commencing exercise . Higher capacity after exe training may encourage patients to lead more active lifestyle which would maintain a higher peak VO2 long-term . Exercise must be continued to maintain benefit.

62. NICE Guidelines � should give you the information you ask for or need about heart failure, the treatments and the possible side effects� Expert Diagnosis and treatment Protocols Education tools �..should work in a constructive partnership with you and your family or carers at all times, including when decisions need to be made about your care.� �..should offer help and support to cope with any effects that chronic heart failure have on your daily life.�

63. Dyssynchrony Progressive ventricular remodelling