3Risk Factors Smoking DM Obesity Alcohol High total chol:HDL ratio LVH on echoCongenital heart defectsValvular disorders in elderlyViral myocarditisFamily historyDrug relatedKeep
4Symptoms LVF RVF SOB, Orthopnoea, PND Decreased exercise tolerance LethargyNocturnal coughWheezeRVFSwelling of anklesAbdominal discomfort due to liver distensionNausea and AnorexiaFatigue and WastingIncreased weightkeep
5NYHA Class Patient Symptoms Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea (shortness of breath).Class II (Mild)Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnoea.Class III (Moderate)Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnoea.Class IV (Severe)Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.keep
7Investigations 12 lead ECG Natriuretic peptides CXR FBC, TFT, E&E, creatinine, eGFR, LFTs, glucose and lipidsUrinalysis, peak flow, spirometryEchoKeep
8Natriuretic PeptidesMeasurement of natriuretic peptide levels helps to determine:The likelihood of the presence of heart failure.The need for referral for specialist assessment and confirmation of the diagnosis by echocardiography.The urgency of the referral.keep
9Natriuretic PeptidesTwo types of natriuretic peptide can be measured: B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-pro-BNP) (Local Lab uses NT-pro-BNP).NT-proBNP is the inactive prohormone of BNP and is secreted from the ventricles in response to volume expansion and pressure overload (as occurs in heart failure).BNP increases renal excretion of sodium (natriuresis) and water (diuresis) and relaxes vascular smooth muscle, which leads to vasodilation.Keep add local lab uses NT-pro-BNP.
10Natriuretic PeptidesIncreased levels of BNP or NT-proBNP are present in:left ventricular hypertrophy, myocardial ischaemia, atrial fibrillation, pulmonary hypertension, hypoxia, pulmonary embolism, right ventricular strain, chronic obstructive pulmonary disease, liver failure, sepsis, diabetes, and renal impairment, in people older than 70 years of age and in women.Levels are lower in people who are obese or are taking drug treatments, such as aldosterone antagonists, angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, beta-blockers, and diuretics.keep
11ReferralRefer urgently (within 2 weeks) for specialist assessment and echocardiography:People who have had a previous myocardial infarction (MI).People without a history of MI who have high levels of natriuretic peptide — N-terminal pro-B-type natriuretic peptide (NT-proBNP) level above 2000 pg/mL (236 pmol/L).People with severe symptoms (if admission is not indicated).Women who are pregnant.Remove BNP figures
12Referral Refer within 6 weeks: People without a history of MI who have a NT-proBNP level between 400–2000 pg/mL (47–236 pmol/L).If natriuretic peptide levels are normal (NT-proBNP less than 400 pg/mL [47 pmol/L]), a diagnosis of heart failure is unlikely. However, referral may still be needed if:Clinical suspicion of heart failure persists and the person is obese or taking drugs which lower natriuretic peptide levels (diuretics, angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, beta-blockers, or aldosterone antagonists).Another condition is suspected, which requires referral to a specialist.Last bullet removed re if not possible to measure – BNP figures removed
14Management Non-drug Mx: 1. Educate 2. Discuss ways to make life easier 3. Diet4. Lifestyle measures5. Restrict fluid intake6. Vaccination7. Asses for depressionKeep
15Management While patient is awaiting referral:- Drug MX: Improve Survival1. ACE-I /ARB2. beta blockers.Remove symptoms – only ACE-1/ ARB and Beta Blockers - add in what to do while patient is awaiting referral
16How should I manage the person while they are waiting to see a specialist? If possible, stop any drugs that may affect the person's heart failure, such as nonsteroidal anti-inflammatory drugs (including those bought over the counter) or calcium-channel blockers.If symptoms are sufficiently severe to warrant treatment (but not admission), start a loop diuretic:Furosemide 20 mg/day to 40 mg/day.Bumetanide 0.5 mg/day to 1.0 mg/day.Torasemide 5 mg/day to 10 mg/day.Seek specialist advise for pregnant women before initiating any drug treatments.Keep
18Angela Graves MSc BSc RN Heart Failure Nurse Manager/Nurse Practitioner East Lancashire Heart Failure Nursing Service East Lancashire Hospitals NHS Trust
19The impact of heart failure The National Heart Failure Audit Report (2010) suggests that heart failure affects one in every hundred here in the UK with this figure rising steeply for those over 75 years to 7%.Cost to the National Health Service of heart failure is approximately £625 million, predominantly due to emergency admissions.NICE (2010) argue that with appropriate diagnosis, treatment and management morbidity and mortality can be greatly improved.
20PrognosisPrognosis is poor on the whole, with approximately 50% of people with heart failure dying within four years of diagnosis. Within a year of admission to hospital 32% of patients will dieThe mortality rate in the UK appears to be improving. A UK study found that the six-month mortality rate for people with heart failure had improved from 26% in 1995 to 14% in 2005.The prognosis for people with heart failure and preserved left ventricular ejection fraction is a little better than the prognosis for people with heart failure and reduced ejection fraction.Add to Angel’s slides
21ELHT Heart Failure Nursing Service- What we offer The Link from Primary to Secondary CareReview of patient as in patientCommunity ClinicsOptimisation of medicationOn going management and supportLimited home visiting servicePatients in end stage heart failure
22Supportive Services Heart Failure Nursing Service Cardiac Rehabilitation TeamsCommunity Matron/District NursingPalliative Care Teams- Hospice services,
23Case Study 135 year old Mr Y attends for review; he first consulted you with flu symptoms approximately 8 weeks ago. He says his symptoms are getting worse; his exercise capacity has been markedly reduced, is orthopneic, and is complaining of weight gain particularly in relation to his abdomen. You order routine bloods and find deranged LFTs, what are your next steps in this management of this patient?
24Answer - Case Study 1Full bloods U/Es, egfr, LFTs, FBC, Thyroid function, Pro BNP, ESR, CRPECGECHOCardiology Review does he require hospital admissionCXRSupport network Pumping Marvellous
25Case Study 2Mrs V aged 85 yrs, is reviewed at home, which is a home for the elderly, she has a history of IHD and recent ECHO you ordered has shown an LVEF of 35%. She experiences no chest pain, but has increasing shortness of breath, mild peripheral oedema, and is currently taking statin, aspirin, Atenolol 25mg, and Ramipril 1.25mg. What medication would you initiate and referrals make?
26Answer – Case Study 2 Managed by the practice Review of medication, switch to appropriate Beta BlockerUp to date bloods look to titrate ACEIntroduction of loop diureticEducation to staff in the home- what to look out forPPC what does Mrs V want