1. HEART FAILURE

2. Excellent Care 1. Diagnosis 2. ACE-I and B blocker 3. Aldosterone antagonist 4. Exercise 5. Statin and aspirin if CVD 6. Digoxin with AF 7. Lifestyle 8. Ivabradine 9. Monitoring

3. Diagnosis 1. ECG 2. BNP 3. CXR – for possible alternative diagnoses (together with blood tests and spirometry) 4. Echo

4. Drug therapy 1. ACE-I (or ARB if not tolerated). Titrate to evidence based dose – practically speaking this is usually the maximum dose. 2. Bisoprolol, carvedilol (or nebivolol for those over 70). A 20,000 patient (23 trial) meta analysis found 18% reduction in risk of death for every 5 bpm reduction in resting HR. No correlation between dose and death, ie higher doses are not better at reducing deaths than lower doses. The study strongly suggests reducing pulse is more important than dose. In sinus rhythm aim for 60 bpm. If resting pulse falls to < 50, halve the B blocker dose. In HF + AF keep HR > 70. Aim for 73 – 82 bpm. ?Prevents bradyarhythmias at night.

5. Drug therapy (cont) 3. Aldosterone antagonist. Spironolactone or eplerenone. Used to be recommended in NYHA III – IV if EF =/<35%. New evidence – use in NYHA II – IV (with EF =/<35%). 4. Aspirin and statin if CVD. 5. With AF & HF, if pulse not reduced to 73 – 82 bpm by B blocker, then add digoxin. 6. Ivabradine – specialist use only – not if any risk of AF.

6. Exercise and Lifestyle NICE: “Offer a supervised group exercise- based rehabilitation programme designed for patients with Heart Failure. Ensure the patient is stable and does not have a condition or device that would preclude the programme. …psychological and educational component.” Smoking, alcohol, sexual activity, imms.

7. Monitoring 1. Functional capacity, fluid status, rhythm, cognitive and nutritional status 2. Drugs 3. U&Es and eGFR. When starting aldosterone antagonist check U&Es 7 – 14 days later, with each dose change, and eventually at the very least every 6 months. Amiodarone needs 6 monthly TFTs & LFTs. Initially monitor patient’s clinical condition at short intervals (days to 2 wk) if condition / drugs change. Otherwise monitor at least 6 monthly.

8. 4 Questions 1. Diagnosis. Primary Care – Can take several wks from decision for echo to results. Echos on ICE? Secondary Care – Should all patients with heart failure diagnosis have an echo while in patient. Need to know if heart failure symptoms or actual LVSD. If not possible, then ?hospital BNP screen followed by echo if positive.

9. 4 Questions 2. Titrating B blockers Aim for pulse of 60 bpm, not dose of B blocker. 72 – 83 bpm in AF.

10. 4 Questions 3. Blood monitoring U&Es after initiation and after every dose change of ACE-I / ARB / spironolactone. BNF: Thereafter minimum 6 monthly U&Es Also 6 monthly TFTs and LFTs if on amiodarone

11. 4 Questions 4. Frequency of patient clinical monitoring 6 monthly monitoring when stable.(NICE) ?Alternating between practice nurse and GP.