1 / 29

Management of Chronic Heart Failure

Management of Chronic Heart Failure. Dr A Al-Mohammad, MD, FRCP(Edin ), FRCP(Lond ) Consultant Cardiologist Sheffield Teaching Hospitals NHS Foundation Trust 22 nd March 2012. Conflicts of Interest. PI for Emphasis and STICH in Sheffield

umay
Download Presentation

Management of Chronic Heart Failure

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Management of Chronic Heart Failure Dr A Al-Mohammad, MD, FRCP(Edin), FRCP(Lond) Consultant Cardiologist Sheffield Teaching Hospitals NHS Foundation Trust 22nd March 2012

  2. Conflicts of Interest • PI for Emphasis and STICH in Sheffield • Clinical Advisor to the Guideline Development Group at NICE for the Chronic Heart Failure – Partial Update (NICE CG-108 2010) • Member of the Topic Expert Group on CHF at NICE, producing Quality Standards 2011; and currently working on CHF COF+QOF

  3. Background • Static incidence but increasing prevalence • Increasingly important role of primary care in managing CHF • NICE guidelines 2010 • Further evidence

  4. The diagnosis algorithm • Please see the algorithm on www.nice.org.uk

  5. The role of ACEI in HF • ACEI in the first line of therapy for HF-LVSD • The evidence was inadequate to support their use in HFPEF. • Start ACEI at a low dose and titrate upwards at short intervals until the optimal tolerated or target dose is achieved. • Measure serum U+E+creat, and eGFR at initiation of an ACEI and after each dose increment.

  6. The role of Beta Blockers in HF (1) • BB in the first line of therapy for HF-LVSD • Offer both ACEI and BB licensed for HF, to all pts with HF due to LVSD. Use clinical judgment when deciding which drug to start first. • Offer BB licensed for HF to all pts with HF due to LVSD, including: older adults and pts with: PVD erectile dysfunction DM interstitial pulmonary disease COPD without reversibility. NICE Clinical Guideline 108, August 2010

  7. The role of Beta Blockers in HF (2) • Introduce BB in a ‘start low, go slow’ manner, and assess HR, BP, and clinical status after each titration. • Switch stable pts who are already taking a BB for a co-morbidity, and who develop HF due to LVSD, to a BB licensed for HF. NICE Clinical Guideline 108, August 2010

  8. The role of Aldosterone Antagonists in HF • One of the second- line treatments for HF-LVSD. • In pts with HF due to LVSD who are taking AA, closely monitor potassium and creatinine levels, and eGFR. • Seek specialist advice if the pt develops hyperkalaemia or renal function deteriorates • For pts who have had an acute MI and who have symptoms and/or signs of HF and LVSD, treatment with an AA licensed for post-MI treatment should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy. • Pts who have recently had an acute MI and have clinical HF and LVSD, but who are already being treated with an AA for a concomitant condition (for example, chronic heart failure), should continue with the AA or an alternative, licensed for early post-MI treatment. NICE Clinical Guideline 108, August 2010

  9. Emphasis-HF Trial • Eplerenone (mean dose of 39 mg or placebo) were added to optimal first line therapy (93-94% were on ACEI, ARB or both; and over 86% were on BB). • 2737 pts aged > 55 years with mild symptoms of HF (NYHA class II), who had either been hospitalized in the last 6 months, or their NP levels were still elevated despite therapy at (BNP>250 pg/ml, or NT-proBNP of >500 pg/ml in men or >750 pg/ml in women). • Significantly lower rates of hospitalization and mortality (from heart failure, cardiovascular causes and all cause).

  10. The role of Hydralazine and nitrates in HF(1) • One of the agents of second line treatment for HF-LVSD • Seek specialist advice and consider hydralazine in combination with nitrate for pts with HF due to LVSD who are intolerant of ACEI and ARBs. NICE Clinical Guideline 108, August 2010

  11. H/N treatment • VHEFT I • VHEFT II • AHEFT: 43% RRR in the rate of any cause mortality 33% RRR in the rate of HF hospitalisation

  12. The role of Angiotensin Receptor Blockers in HF(1) • One of the agents of second line therapy for HF-LVSD. • Consider an ARB licensed for HF as an alternative to an ACEI for pts with HF due to LVSD who have intolerable side effects with ACEI. • Monitor serum u+e, creatinine and eGFR for signs of renal impairment or hyperkalaemia in pts with HF who are taking an ARB NICE Clinical Guideline 108, August 2010

  13. Still symptomatic after first and second line therapy for HF-LVSD • Digoxin is recommended for worsening or severe HF-LVSD, • Consider CRT-P/D

  14. When to use diuretics? • Congestion and fluid overload. • Mainstay of therapy in HFPEF, in addition to treating co-morbidity

  15. Heart Failure with Preserved Ejection Fraction • Diagnosis, with Specialist advice, and management with diuretics (around 80 mg/d of furosemide) & treatment of co-morbid conditions

  16. The treatment algorithm • Please, see the algorithm on www.nice.org.uk

  17. Shift Study • Ivabradine is a new class not previously used in heart failure. • An inhibitor of the If current in the SA node. • SHIFT trial: 6558 pts hospitalized because of HF in the preceding year, in SR with HR> 70 bpm, and who were taking beta-blockers if tolerated, were randomized to ivabradine or placebo. • Ivabradine reduced HF hospitalization by 26% and HF mortality by 26%. • Interpretation of the results of SHIFT will depend upon the extent to which the study population is felt to truly have been on optimal BB.

  18. Monitoring • When a pt is admitted to hospital because of HF, seek advice on their management plan from a specialist in HF. • Consider specialist monitoring of serum NP in some pts. • No specific recommendation for home telemonitoring. • All pts with HF require monitoring: clinical assessment of functional capacity, fluid status, cardiac rhythm, cognitive and nutritional status, review of medication. • More detailed monitoring when there is significant comorbidity or if u+e+eGFR has deteriorated. • The frequency of monitoring (2/52-6/12).

  19. Rehabilitation • Offer a supervised group exercise-based rehabilitation programme designed for patients with HF. • Ensure the patient is stable and does not have a condition or device that would preclude an exercise-based rehabilitation programme. • Include a psychological and educational component in the programme.

  20. When to refer to a specialist? Refer patients to the specialist MDT for: • the initial diagnosis of HF • the management of: -severe HF (NYHA class IV) -HF that does not respond to treatment -HF that can no longer be managed effectively in the home setting.

  21. The Specialist and HF MDT • “Specialist”: A a physician with sub-specialty interest in HF (often a consultant cardiologist) who leads a specialist HF-MDT of professionals with appropriate competencies from primary and secondary care. • MDT will involve, where necessary, other services (such as rehabilitation, tertiary care and palliative care) in the care of individual patients.

  22. Thus… (1) • Until the diagnosis is confirmed, treat the symptoms with diuretics and appropriate other measures (after sending blood for NP) • When the diagnosis of HF-LVSD is made, treat with ACEI+BB(HF) • If the diagnosis is HFPEF, then treat with diuretics + evidence-based therapy for co-morbidity (systemic hypertension, IHD, DM, AF) • The same applies when a patient is discharged from STH with the HF diagnosis

  23. Thus…(2) • Please, uptitrate the ACEI and BB to the maximum tolerated doses • Do not change ACEI to ARB UNLESS the SE are intolerable (not equivalent) • If ACEI and ARB can NOT be given, then treat with hydralazine up to 50 mg bd and ISMN 10-20 mg bd asymmetrically

  24. Thus…(3) • If the patient remained symptomatic despite OPTIMAL therapy with ACEI+BB, then DW specialist re AA • Alternatives include ARB or combined H/N • If despite 1st and 2nd line therapy, the patient is symptomatic, DW specialist re other interventions (digitalis, CRT, Tx and other surgical interventions)

  25. Thus…(4) • Monitoring.. Frequency, .. Includes… • Rehabilitation • Team working • Palliation, and the EXCURSION ticket

  26. The roles of the primary care physician and team in the care of CHF patients(1) • Full history and physical examination • Carry out: ECG, blood tests (FBC, U+E, creat, eGFR, glucose, lipids, TFT, LFT), CXR, spirometry. • Post-MI: Refer for TTE and specialist clinical assessment to be done in 2/52 • No PMH of MI: Check NP. • NP not raised, think again • NP is high (TTE + assessment in 2/52), raised (TTE + assessment in 6/52)

  27. The roles of the primary care physician and team in the care of CHF patients(2) • Establish pt with HFPEF on diuretics and treat co-morbidity according to NICE guideline • Establish pt with HF-LVSD on 1st line therapy with ACEI+BB licensed for HF • Monitor patients • Refer HF patients for rehabilitation • If symptoms persist despite optimal therapy, then seek specialist opinion

  28. The roles of the primary care physician and team in the care of CHF patients(3) • Following discussion with the specialist, the patient is established on 2nd line therapy • Consider involving palliative care where appropriate • Re-assess pts following hospitalisation in liaison with the HF MDT • MDT has major input from primary care • Establish primary care audit

  29. Dr A Al-Mohammad Thank you

More Related