1. Heart Failure in Primary care
Lucy McGurn Sarah Green

2. Learning Objectives Increased awareness of the scale of the problem
Improved knowledge of the most appropriate general investigations
Confidence with drug management of heart failure
Increased awareness of non-pharmacological interventions and their effectiveness
Improved understanding of when to refer on to secondary care

3. Heart Failure
Occurs when output of the heart is inadequate to meet the needs of the body
End stage of all diseases of the heart
Prevalence 1-1.6% (10-20% >75yrs)
Poor prognosis can be improved by early and optimal treatment
Increasingly important as population ages
Causes – IHD, hypertension, valvular disease, alcohol, hyperthyroidism

4. Mr Jones is an 78-year-old widower who has attended
your afternoon surgery because of increasing
shortness of breath and fatigue on exertion. He says he
is struggling to play a whole round of golf.
He was last seen in his over-75 health check when it
was noted that his BP was 160/80 with a BMI of 29.8,
but otherwise there were no problems identified.
He has been a lifelong smoker and his diet has been poor
since his wife died of breast cancer 4 years ago.
What do you think is wrong with Mr Jones?

5. Making the diagnosis - Symptoms
LVF (back pressure into pulmonary system)
SOB on exertion Nocturnal cough PND
Orthopnoea Wheeze Lethargy
Reduced exercise tolerance
RVF (back pressure into peripheral circulation)
Ankle oedema Nausea and anorexia
Fatigue and wasting Abdo pain due to hepatomegaly
Increased weight
CCF (failure of both ventricles)
(Remember to ask about chest pain and palpitations)

6. New York Heart Association Classification of Heart Failure
Class I - No limitations
Ordinary physical activity does not cause undue fatigue dyspnoea or palpitation
(asymptomatic left ventricular dysfunction)
Class II - Slight limitation of physical activity
Such patients are comfortable at rest. Ordinary physical activity results in
Fatigue, palpitation, dyspnoea or angina pectoris (symptomatically‚ mild heart failure)
Class III - Marked limitation of physical activity
Although patients are comfortable at rest, less than ordinary physical activity will lead to
symptoms (symptomatically‚ moderate heart failure)
Class IV: Inability to carry on any physical activity without discomfort
Symptoms are present even at rest. With any physical activity increased discomfort is
experienced (symptomatically‚ severe heart failure)

7. You examine Mr Jones – what might you find??

8. Making the diagnosis - Signs
Cachexia and muscle wasting
Tachypnoeic +/- cyanosis
Tachycardia +/- gallop rhythm
Cardiomegaly and displaced apex
Right ventricular heave
Raised JVP
Basal creps +/- effusions +/- wheeze
Ankle oedema
Hepatomegaly
Ascites

9. When you examine Mr Jones you find signs of left and right heart failure. What further investigations do you want??

10. Making the diagnosis - investigations
Weight – good for trend BP
ECG – IHD changes, LVH, slow AF
Bloods – U&E, TFT, LFT, FBC, Lipids, Gluc, natriuretic peptides
CXR
Urinalysis
PEFR/spirometry – if uncertain about Dx

11. Making the diagnosis –NICE Guidance
New guidance 2010 replacing 2003
Good algorithm on diagnosis of heart failure in quick reference guide
If previous MI refer
If no previous MI then measure natriuretic peptides

12. You measure Mr Jones BNP when comes back at 256 pg/ml What do you do next? – follow NICE algorithm When would you refer to secondary care – think about the patients you see in your practice with heart failure.

13. When to refer to specialist multidisciplinary team?
Initial diagnosis of heart failure
Severe HF (class IV)
HF not responding to treatment
HF due to valve disease
HF that can’t be managed at home
Women thinking of pregnancy
Suspected HF and previous MI – urgent 2/52

14. Mr Jones attends hospital and has an echo showing a reduced ejection fraction. The Cardiologist starts him on 2 medications what might they be?

15. Mr Jones attends hospital and has an echo showing a reduced ejection fraction. The Cardiologist starts him on 2 medications what might they be? Combination of an ACE-inhibitor and β-blocker

16. Treatment of heart failure – ACE Inhibitors
- Captopril, Enalapril, Lisinopril, Ramipril
- Start low and titrate up every 2/52
- Monitor U&E, eGRF & BP – at initiation/after increase (expect small increases)
- if suspect valve disease don’t start
- use angiotensin II receptor antagonist if SE’s
(valsartan, candesartan, losartan)

17. Treatment of heart failure - βblockers
- Carvedilol, bisoprolol (short-acting)
- Good for HF due to LVSD
- Start low and titrate up every 2/52
- monitor HR, BP, clinical status
- can give to elderly, PVD, diabetes, interstitial pulmonary disease COPD (without reversibility)
- don’t just stop as get rebound – ischaemia/arrythmias

18. You managed to get him stable on his medications with initial frequent monitoring. He then remains well for the next few years with 6 monthly checks. Mr Jones returns to see you with worsening ankle oedema and increasing SOB. He says he has had to stop playing golf and is even having difficulty managing the hill up to the corner shop. What is his NYHA class now? What drug might you add in?

19. Treatment of heart failure – diuretics
Loop (furosemide) or thiazides (bendroflumethiazide)
Use minimum effective dose to control congestive symptoms and fluid retention
Monitor for hypokalaemia
What else could you recommend??

20. Lifestyle and Rehabilitation
Educate – about the disease, current/expected symptoms, need for Rx, prognosis Discuss ways to make life easier – e.g. Benefits, mobility aids, blue badge, social services assessment for extra help Diet – adequate calories, low salt, lose weight if obese, restrict alcohol

21. Lifestyle and Rehabilitation
Lifestyle measures – smoking cessation, regular exercise Restrict fluid intake – litres/day Vaccination – pneumococcal + annual influenza Assess for depression

22. You are asked to do a home visit to see Mr Jones as he rang earlier saying his breathing was a bit worse than usual this morning. On arrival at his house it takes Mr Jones at least 5 minutes to answer the door. He is acutely short of breath and is having difficulty speaking in full sentences. He mentions some tightness in his chest. What may have happened?? What would you check??

23. You are asked to do a home visit to see Mr Jones as he rang earlier saying his breathing was a bit worse than usual this morning. On arrival at his house it takes Mr Jones at least 5 minutes to answer the door. He is acutely short of breath and is having difficulty speaking in full sentences. He mentions some tightness in his chest. What may have happened?? What would you check?? You confirm fast AF with gross pulmonary oedema and ring for an ambulance.

24. Atrial Fibrillation
Can be difficult to know if AF is the cause or an effect of heart failure
Digoxin used as improves ejection fraction as well as decreasing hospital admissions
Increasing prevalence with worsening heart failure Class I – 4%
Class II %
Class III – 20-29%
Class IV – 50%

25. Mr Jones has 4 further hospitals admissions over the next few months
Mr Jones has 4 further hospitals admissions over the next few months. He now has home care going in twice a day. The district nurse asks you to go and see him as she feels he is getting worse again. What issues should you raise?

26. Longterm care and palliation
Poor prognosis - progressive deterioration to death
50% die suddenly – probably due to arrhythmias
Mild/Moderate HF 20-30% 1yr mortality
Severe HF >50% 1yr mortality
Make use of specialist heart failure nurses
Involve palliative care
Think about resuscitation status

27. References/Resources
Oxford Handbook of General Practice, Simon, Everitt and Kendrick, Oxford University, 2005
Chronic Heart Failure – Quick reference guide, NICE, Aug 2010
E-learning module – doctors.net
British Heart Foundation Website