Presentation on theme: "Heart Failure in Primary care"— Presentation transcript:
1Heart Failure in Primary care Lucy McGurn Sarah Green
2Learning Objectives Increased awareness of the scale of the problem Improved knowledge of the most appropriate general investigationsConfidence with drug management of heart failureIncreased awareness of non-pharmacological interventions and their effectivenessImproved understanding of when to refer on to secondary care
3Heart FailureOccurs when output of the heart is inadequate to meet the needs of the bodyEnd stage of all diseases of the heartPrevalence 1-1.6% (10-20% >75yrs)Poor prognosis can be improved by early and optimal treatmentIncreasingly important as population agesCauses – IHD, hypertension, valvular disease, alcohol, hyperthyroidism
4Mr Jones is an 78-year-old widower who has attended your afternoon surgery because of increasingshortness of breath and fatigue on exertion. He says heis struggling to play a whole round of golf.He was last seen in his over-75 health check when itwas 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 poorsince his wife died of breast cancer 4 years ago.What do you think is wrong with Mr Jones?
5Making the diagnosis - Symptoms LVF (back pressure into pulmonary system)SOB on exertion Nocturnal cough PNDOrthopnoea Wheeze LethargyReduced exercise toleranceRVF (back pressure into peripheral circulation)Ankle oedema Nausea and anorexiaFatigue and wasting Abdo pain due to hepatomegalyIncreased weightCCF (failure of both ventricles)(Remember to ask about chest pain and palpitations)
6New York Heart Association Classification of Heart Failure Class I - No limitationsOrdinary physical activity does not cause undue fatigue dyspnoea or palpitation(asymptomatic left ventricular dysfunction)Class II - Slight limitation of physical activitySuch patients are comfortable at rest. Ordinary physical activity results inFatigue, palpitation, dyspnoea or angina pectoris (symptomatically‚ mild heart failure)Class III - Marked limitation of physical activityAlthough patients are comfortable at rest, less than ordinary physical activity will lead tosymptoms (symptomatically‚ moderate heart failure)Class IV: Inability to carry on any physical activity without discomfortSymptoms are present even at rest. With any physical activity increased discomfort isexperienced (symptomatically‚ severe heart failure)
8Making the diagnosis - Signs Cachexia and muscle wastingTachypnoeic +/- cyanosisTachycardia +/- gallop rhythmCardiomegaly and displaced apexRight ventricular heaveRaised JVPBasal creps +/- effusions +/- wheezeAnkle oedemaHepatomegalyAscites
9When you examine Mr Jones you find signs of left and right heart failure. What further investigations do you want??
10Making the diagnosis - investigations Weight – good for trendBPECG – IHD changes, LVH, slow AFBloods – U&E, TFT, LFT, FBC, Lipids, Gluc, natriuretic peptidesCXRUrinalysisPEFR/spirometry – if uncertain about Dx
11Making the diagnosis –NICE Guidance New guidance 2010 replacing 2003Good algorithm on diagnosis of heart failure in quick reference guideIf previous MI referIf no previous MI then measure natriuretic peptides
12You 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.
13When to refer to specialist multidisciplinary team? Initial diagnosis of heart failureSevere HF (class IV)HF not responding to treatmentHF due to valve diseaseHF that can’t be managed at homeWomen thinking of pregnancySuspected HF and previous MI – urgent 2/52
14Mr Jones attends hospital and has an echo showing a reduced ejection fraction. The Cardiologist starts him on 2 medications what might they be?
15Mr 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
16Treatment 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)
17Treatment 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
18You 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?
19Treatment of heart failure – diuretics Loop (furosemide) or thiazides (bendroflumethiazide)Use minimum effective dose to control congestive symptoms and fluid retentionMonitor for hypokalaemiaWhat else could you recommend??
20Lifestyle 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
22You 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??
23You 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.
24Atrial FibrillationCan be difficult to know if AF is the cause or an effect of heart failureDigoxin used as improves ejection fraction as well as decreasing hospital admissionsIncreasing prevalence with worsening heart failure Class I – 4%Class II %Class III – 20-29%Class IV – 50%
25Mr 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?
26Longterm care and palliation Poor prognosis - progressive deterioration to death50% die suddenly – probably due to arrhythmiasMild/Moderate HF 20-30% 1yr mortalitySevere HF >50% 1yr mortalityMake use of specialist heart failure nursesInvolve palliative careThink about resuscitation status
27References/Resources Oxford Handbook of General Practice, Simon, Everitt and Kendrick, Oxford University, 2005Chronic Heart Failure – Quick reference guide, NICE, Aug 2010E-learning module – doctors.netBritish Heart Foundation Website