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Managing Heart Failure

Managing Heart Failure. Steve Leslie Consultant Cardiologist (NHS Highland) Honorary Professor (University of the Highlands and Islands). The heart is a pump. But it can go wrong. Annual Survival. 100. Melanoma. Breast. 90. Prostate. 80. 70. HF. Colorectal. 60. 1 year %. 50.

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Managing Heart Failure

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  1. Managing Heart Failure Steve LeslieConsultant Cardiologist (NHS Highland)Honorary Professor (University of the Highlands and Islands)

  2. The heart is a pump

  3. But it can go wrong

  4. Annual Survival 100 Melanoma Breast 90 Prostate 80 70 HF Colorectal 60 1 year % 50 survival 40 30 Lung 20 10 0 Office for National Statistics (2001) Quinn M, Babb P, Brock A, Kirby L and Jones J. Cancer trends in England and Wales 1950-1999. Cowie et al :Heart 2000;83:505

  5. Prognosis Difficult to predict time of death Challenging in CHF due to: Cyclical nature of disease Complexity of care Recent advances, especially in the area of medical interventions

  6. ‘Drop’ or ‘Drown’ Mechanism of death in CHF Sudden cardiac death Brady- or tachyarrhythmias Progressive heart failure Varies depending on NYHA class NYHA class II – higher risk of sudden death (drop) NYHA class IV – increasing dyspnoea/ orthopnea, decreased BP (drown) Arnold et al. CCS Can J Cardiol 2006

  7. Change in Aetiology McMurray, J. J et al. Heart 2000;83:596-602

  8. Prevalence of coronary disease Coronary Heart Disease Statistics (2003) Eur Heart J 2008 29:1316-1326

  9. NHS Highland • 10,000 coronary artery disease • 10,000 high blood pressure patients • 600 heart attacks • 450 coronary stents • 80 CABG • 800 cardiac rehab referrals • 1500 heart failure patients

  10. It is our own fault! • Despite our best efforts to smoke, drink and eat ourselves to death • We are living longer!

  11. Heart Failure is more prevalent in older people

  12. Trends in Mortality Decline in adjusted risk of dying within 30 days after first heart failure admission. Decline in adjusted risk of dying after 30 days following a first heart failure admission.

  13. Hospital Admissions McMurray et al EHJ 1998:19:9

  14. Average Length of Hospital Admission Coronary heart disease statistics: heart failure supplement., BHF 2002, http://www.heartstats.org, Based on Hospital Episode Statistics DOH 2001 at http://www.dh.gov.uk/publicationsandstatistics/statistics/hospitalepisodestatistics/fs/en

  15. More people living with a chronic condition The majority of patients with heart failure don’t die of heart failure

  16. Diagnosing heart failure remains tricky / suboptimal / variable “Too many patients diagnosed on admission to hospital…………….often despite weeks of symptoms in the community”

  17. Diagnosing heart failure

  18. Signs and symptoms of heart failure Left sided Right sided Biventricular

  19. Left Heart Failure Symptoms Breathlessness (NYHA) Paroxysmal nocturnal dyspnoea Orthopnoea Fatigue, generalized weakness

  20. Left Heart Failure Signs Anxiety, confusion, restlessness Persistent cough Pink, frothy sputum Tachycardia Tachypnoea, crackles (nb wheeze) Cyanosis (late) Third heart sound (S3)

  21. Right Heart Failure – Signs and Symptoms Tachycardia Jugular vein distension Pedal, pre-tibial, sacral oedema Hepatomegaly Splenomegaly

  22. Definition of Heart Failure Heart Failure is a clinical syndrome where: Heart and circulation are unable to meet the demands of the body Pump failure (systolic) HFrEF Or only able to do so at an abnormally elevated diastolic pressure (diastolic) HFpEF

  23. ESC definition

  24. Making the diagnosis • Unlike chronic stable angina – you need tests!

  25. Diagnostic flow diagram

  26. Signs and Symptoms

  27. BNP

  28. Echocardiography for LV assessment Direct access echocardiography ?LVSD • 20% have LVSD • 45% LVH • 10% valves • 25% normal

  29. Aetiology of heart failure

  30. Heart Failure Diagnosis • Difficult clinical diagnosis • High level of suspicion • Simple tests first • Refer for echocardiography • Don’t delay treatment • Think about the aetiology

  31. Treatment HFrEF

  32. Considerations • Acute vs deteriorated chronic • Left vs right heart failure • LV impaired vs preserved • Life prolonging vs life improving • Palliative stage of heart failure

  33. Treating heart failure - location • Community • Stable heart failure with a diagnosis and treatment plan • Local hospital (no echo no specialists) • Deteriorations in chronic patients • Immediate stabilisation of new patients • Secondary / tertiary care (cath lab, echo, cardiologist) • New patients with acute heart failure • Quaternary care • Transplantation / LVAD

  34. Treating acute HFrEF • Acute presentations e.g. pulmonary oedema • ABC approach • Think of the cause – is this a myocardial infarction? • Poor evidence base for most treatments but early PCI saves lives • Oxygen, IV morphine, IV furosemide, CPAP, early IV nitrates • Manage arrhythmia e.g. VT • Take care with rate limiting drugs can make things worse – early expert advice.

  35. Treating acute HFrEF • Look for and treat reversible causes early • Myocardial ischaemia • Hypertension • Anaemia (difficult to treat acutely) • ECG monitoring – high risk of sudden death • Early specialist advice • Ceiling of care discussions early

  36. What can we do in Raigmore? • Specialist advice • CCU / echo / cath lab / CPAP • IABP – consider transfer to advanced heart failure unit

  37. Intra-aortic balloon pump

  38. Treating chronic HFrEF • Evidence based and international consensus • Clear guidelines (SIGN / NICE) • Investigations • Drugs • Non pharmacological interventions • Devices • Palliative care

  39. Hospital investigations • Echo – cheap safe good assessment of LV for most • MRI – better image quality • Angio – excludes coronary disease • Stress testing? – is myocardium viable?

  40. Drugs (low and go slow) • Betablocker • (bisoprolol / carvedilol) • Renin angiotensin system blockade • (ACEi, ARB, entresto) • Mineralocorticoid inhibitors • (spirolactone / eplerenone) • Ivabradine • Aim to get furosemide dose as low as possible

  41. Non pharmacological interventions

  42. Heart Failure and Exercise Metres Weeks training Kavanagh Heart 1996;76:42

  43. Training and neurohormones Ang II Aldo AVP ANP 10 0 -10 -20 -30 -40 Trained Control -50 J Am Coll Cardiol 1999;34:1170

  44. Training

  45. Heart Failure and Exercise • Exercise need not be discouraged • Formal training programmes • Improve symptoms • Improve adverse prognostic factors • Might improve survival • If a drug improved exercise capacity by 20% ….

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