Dr. Ali Gpst3 Brownhill Surgery Heart Failure keep Dr. Ali Gpst3 Brownhill Surgery

Outline Risk factors Symptoms Signs Investigations Differential Diagnosis Referral Treatment keep

Risk Factors Smoking DM Obesity Alcohol High total chol:HDL ratio LVH on echo Congenital heart defects Valvular disorders in elderly Viral myocarditis Family history Drug related Keep

Symptoms LVF RVF SOB, Orthopnoea, PND Decreased exercise tolerance Lethargy Nocturnal cough Wheeze RVF Swelling of ankles Abdominal discomfort due to liver distension Nausea and Anorexia Fatigue and Wasting Increased weight keep

NYHA 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

Signs Laterally displaced apex beat Raised jugular venous pressure Enlarged liver Third or fourth heart sound (gallop rhythm) Tachycardia Lung crackles (persisting after coughing) Dependent oedema (legs, sacrum) keep

Investigations 12 lead ECG Natriuretic peptides CXR FBC, TFT, E&E, creatinine, eGFR, LFTs, glucose and lipids Urinalysis, peak flow, spirometry Echo Keep

Natriuretic Peptides Measurement 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

Natriuretic Peptides Two 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.

Natriuretic Peptides Increased 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

Referral Refer 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

Referral 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

Differential dx Obesity Respiratory disease Venous insufficiency in legs Drug induced (CCB,NSAIDs) Hypoalbuminaemia Anxiety Anaemia Thyroid disease Keep

Management Non-drug Mx: 1. Educate 2. Discuss ways to make life easier 3. Diet 4. Lifestyle measures 5. Restrict fluid intake 6. Vaccination 7. Asses for depression Keep

Management While patient is awaiting referral:- Drug MX: Improve Survival 1. ACE-I /ARB 2. beta blockers. Remove symptoms – only ACE-1/ ARB and Beta Blockers - add in what to do while patient is awaiting referral

How 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

Complications Arrythmias Stroke DVT/PE Malabsorption Hepatic congestion Muscle wasting Keep

Angela Graves MSc BSc RN Heart Failure Nurse Manager/Nurse Practitioner East Lancashire Heart Failure Nursing Service East Lancashire Hospitals NHS Trust

The 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.

Prognosis Prognosis 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 die The 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

ELHT Heart Failure Nursing Service- What we offer The Link from Primary to Secondary Care Review of patient as in patient Community Clinics Optimisation of medication On going management and support Limited home visiting service Patients in end stage heart failure

Supportive Services Heart Failure Nursing Service Cardiac Rehabilitation Teams Community Matron/District Nursing Palliative Care Teams- Hospice services,

Case Study 1 35 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?

Answer - Case Study 1 Full bloods U/Es, egfr, LFTs, FBC, Thyroid function, Pro BNP, ESR, CRP ECG ECHO Cardiology Review does he require hospital admission CXR Support network Pumping Marvellous

Case Study 2 Mrs 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?

Answer – Case Study 2 Managed by the practice Review of medication, switch to appropriate Beta Blocker Up to date bloods look to titrate ACE Introduction of loop diuretic Education to staff in the home- what to look out for PPC what does Mrs V want