Heart Failure in Primary care Lucy McGurn Sarah Green

Learning Objectives Increased awareness of the scale of the problem Improved knowledge of the most appropriate general investigations Confidence with drug management of heart failure Increased awareness of non-pharmacological interventions and their effectiveness Improved understanding of when to refer on to secondary care

Heart Failure Occurs when output of the heart is inadequate to meet the needs of the body End stage of all diseases of the heart Prevalence 1-1.6% (10-20% >75yrs) Poor prognosis can be improved by early and optimal treatment Increasingly important as population ages Causes – IHD, hypertension, valvular disease, alcohol, hyperthyroidism

Mr Jones is an 78-year-old widower who has attended your afternoon surgery because of increasing shortness of breath and fatigue on exertion. He says he is struggling to play a whole round of golf. He was last seen in his over-75 health check when it was 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 poor since his wife died of breast cancer 4 years ago. What do you think is wrong with Mr Jones?

Making the diagnosis - Symptoms LVF (back pressure into pulmonary system) SOB on exertion Nocturnal cough PND Orthopnoea Wheeze Lethargy Reduced exercise tolerance RVF (back pressure into peripheral circulation) Ankle oedema Nausea and anorexia Fatigue and wasting Abdo pain due to hepatomegaly Increased weight CCF (failure of both ventricles) (Remember to ask about chest pain and palpitations)

New York Heart Association Classification of Heart Failure Class I - No limitations Ordinary physical activity does not cause undue fatigue dyspnoea or palpitation (asymptomatic left ventricular dysfunction) Class II - Slight limitation of physical activity Such patients are comfortable at rest. Ordinary physical activity results in Fatigue, palpitation, dyspnoea or angina pectoris (symptomatically‚ mild heart failure) Class III - Marked limitation of physical activity Although patients are comfortable at rest, less than ordinary physical activity will lead to symptoms (symptomatically‚ moderate heart failure) Class IV: Inability to carry on any physical activity without discomfort Symptoms are present even at rest. With any physical activity increased discomfort is experienced (symptomatically‚ severe heart failure)

You examine Mr Jones – what might you find??

Making the diagnosis - Signs Cachexia and muscle wasting Tachypnoeic +/- cyanosis Tachycardia +/- gallop rhythm Cardiomegaly and displaced apex Right ventricular heave Raised JVP Basal creps +/- effusions +/- wheeze Ankle oedema Hepatomegaly Ascites

When you examine Mr Jones you find signs of left and right heart failure. What further investigations do you want??

Making the diagnosis - investigations Weight – good for trend BP ECG – IHD changes, LVH, slow AF Bloods – U&E, TFT, LFT, FBC, Lipids, Gluc, natriuretic peptides CXR Urinalysis PEFR/spirometry – if uncertain about Dx

Making the diagnosis –NICE Guidance New guidance 2010 replacing 2003 Good algorithm on diagnosis of heart failure in quick reference guide If previous MI refer If no previous MI then measure natriuretic peptides

You 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.

When to refer to specialist multidisciplinary team? Initial diagnosis of heart failure Severe HF (class IV) HF not responding to treatment HF due to valve disease HF that can’t be managed at home Women thinking of pregnancy Suspected HF and previous MI – urgent 2/52

Mr Jones attends hospital and has an echo showing a reduced ejection fraction. The Cardiologist starts him on 2 medications what might they be?

Mr 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

Treatment 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)

Treatment 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

You 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?

Treatment of heart failure – diuretics Loop (furosemide) or thiazides (bendroflumethiazide) Use minimum effective dose to control congestive symptoms and fluid retention Monitor for hypokalaemia What else could you recommend??

Lifestyle 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

Lifestyle and Rehabilitation Lifestyle measures – smoking cessation, regular exercise Restrict fluid intake – 1.5-2 litres/day Vaccination – pneumococcal + annual influenza Assess for depression

You 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 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.

Atrial Fibrillation Can be difficult to know if AF is the cause or an effect of heart failure Digoxin used as improves ejection fraction as well as decreasing hospital admissions Increasing prevalence with worsening heart failure Class I – 4% Class II -10-26% Class III – 20-29% Class IV – 50%

Mr 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?

Longterm care and palliation Poor prognosis - progressive deterioration to death 50% die suddenly – probably due to arrhythmias Mild/Moderate HF 20-30% 1yr mortality Severe HF >50% 1yr mortality Make use of specialist heart failure nurses Involve palliative care Think about resuscitation status

References/Resources Oxford Handbook of General Practice, Simon, Everitt and Kendrick, Oxford University, 2005 Chronic Heart Failure – Quick reference guide, NICE, Aug 2010 E-learning module – doctors.net British Heart Foundation Website