Heart Failure: From Failure to Success Dr. Alison Seed Consultant Cardiologist

Failures? In diagnosis In routine management In advanced management To address the personal AND financial burden

Diagnosis........... Prevalence >45yrs National (expected) 2.3% Blackpool PCT (recorded) 1.8% (0.19-5) 10-20%>70yrs, to increase 1.Pushing the boundaries: Improving services for people with heart failure. HCC(CHAI ) 2007 2. State of healthcare: Improvements and challenges for services in England and Wales. HCC (CHAI) 2007 3. Blackpool GP HF register data: Brian Harrop, Blackpool PCT

Routine management..........

Implant rate / million population / year Advanced management........ Implant rate / million population / year USA average EU UK target Lancs. South Cumbria 2006 ICD 610 160 100 46 28 Bi V PPM 275 75 140 56 58

Personal and financial burden... Poor prognosis 10-50% mortality per year Poor quality of life Poor exercise tolerance >30% depressive illness Frequent hospital admission 5% of acute medical admissions 40% death /readmission in one year Long length of stay > 8 days 2% of in patient bed days 70% cost is hospitalisation Dr.Seth 530 (2003-2004) – only 5% readmissions 2% total annual NHS expenditure

Cost

Hospital admission length of stay

Healthcare Commission 2007 HF diagnostic services poor Diagnosis difficult because symptoms non specific and physical signs not obvious Early diagnosis leads to appropriate life saving and symptom reducing treatment Limited access to heart failure specialists Need to target advanced treatments at high risk patients Rates of hospitalisation remain high Healthcare Commission. Pushing the boundaries: improving services for people with heart failure. London Healthcare Commission, 2007

........... to our Patients with Heart Failure? Are we offering.......... Advanced Care or Palliative Care ........... to our Patients with Heart Failure?

Palliative Care that could be better !! Currently (2009)…. Inequitable care Only for the symptomatic patient seeking help No more than Crisis management for the majority Palliative Care that could be better !!

National drivers Quality Outcomes Framework ‘Advancing Quality’ (NW SHA) National HF database Darzi report Equitable, efficient, patient centred care Health improvement (outcomes and quality) Adherence to best practice (NICE, NSF) Financial climate Avoid hospital admission Manage chronic disease in primary care

Our aim…. ‘Best care’ whenever and wherever patients require it ............ Not currently seeking attention Not yet diagnosed With confirmed diagnosis New presentation In Primary Care with symptoms Hospital admission(s) With severe heart failure

Our aim.... To demonstrate that optimal care is cost saving...................

Failures? Diagnosis Routine management Advanced management

Definition: The first problem European society of Cardiology: ‘typically breathlessness or fatigue, either at rest or during exercise, or ankle swelling; and objective evidence of cardiac dysfunction at rest (usually on echocardiography)’

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New York Heart Association NYHA > II Further investigation required The NYHA lists.....certainly patients presenting with these symptoms.... Map lists conditions that predispose pts.......surely we should be asking patients who attend.......if they would in fact put themselves in one of these groups. Consider looking for symptoms in at risk population 26

BNP Brain-type Natriuretic Peptide (BNP) is a hormone, secreted in the ventricular myocardium during periods of increased Atrial and ventricular wall tension It is the most powerful marker of cardiovascular morbidity and mortality including sudden death An elevated BNP indicates that the heart or kidneys are not working well but does not tell exactly why

NICE Guidance 2010 28

Heart Failure Diagnostic Clinic One stop Within 2 weeks With regard to confirming the diagnosis......our cardiac centre now offers a one stop The MAP asks you to refer those with alarm features urgently to A&E............ 29

Heart Failure Diagnostic Clinic Comprehensive specialist assessment History/ examination Echocardiogram Consideration of need for further investigation Angiogram, TOE, stress test Management plan Lifestyle Pharmacological Non pharmacological Device therapy Patient education / engagement Majority discharge to primary care ‘additional investigations’ ‘management plan’ Discharge – the majority will be discharged to primary care

HF referral poster AQ data

Failures? Diagnosis Advanced management Routine management

Failures? Diagnosis Advanced management Routine management

Biventricular Pacemakers Right Atrial Lead Right Ventricular Lead

ECG P wave QRS duration

Biventricular Pacemakers Right Atrial Lead Right Ventricular Lead Left Ventricular Lead

Biventricular Pacemakers

Biventricular Pacemakers 36% reduction in All Cause Death / CVS death /Hospitalisation CARE – HF: Cleland et al, NEJM, 2005

Referral for CRT from North Lancs/ Blackpool

Transplant vs. medical Rx Butler et al. J Am Coll Cardiol, 2004 45

Cardiopulmonary exercise testing

Survival following cardiac transplant 1 year: 85% 5 years: 73% 10 years: 58% www.uktransplant.org.uk 47

Mechanical support: Ventricular assist devices Outflow: Ao Inflow: LV/LA

Bridge to transplant Bridge to recovery Destination therapy Who should receive a VAD as bridge to transplant?

Heart Failure Service - Blackpool Timely and accurate diagnosis One stop diagnostic clinic Appropriate/safe/rapid referral pathways Identify high risk patients BNP Efficient and effective clinical care Treatment optimisation (NICE) Non pharmacological intervention (CRT / ICD, LVAD, Tx) Communication , Communication, Communication

Thank you Any questions?