1. HF diagnosis: audit of NTproBNP uptake and outcomes across Sheffield An update on diagnosis and management of HF Dr Abdallah Al-Mohammad, MD, FRCP(Edin), FRCP(Lond), FESC Consultant Cardiologist, Sheffield Teaching Hospitals NHS Foundation Trust PLI 18 11 2015 Sheffield I acknowledge Data on Trends of NTproBNP Testing in Sheffield from Mr John Soady

2. The unique Sheffield 1 In the UK, the place of care for HF patients is: 47.6% in cardiology wards 41.3% in general medicine 10.8% on “other” wards In Sheffield, the place of care for HF patients is: 18-30% in the cardiology wards The remainder are in General Medical wards and others

3. The unique Sheffield 2 The overall in-patient mortality in the UK is 11.1%. The hospital mortality of HF patients is related to place of care: – Cardiology ward (7.8%) – General medical (13.2%) – Other ward (17.4%) – After adjusting for (age>75 yrs, NYHA Class III/IV, previous MI), not being treated in cardiology was still associated with a worse outcome HR=1.66 (1.52-1.81), p<0.001 In Sheffield, although the majority of patients are in Medicine, the mortality overall is closer to those in cardiology wards elsewhere (<10%). The difference is HF MDT

4. CG108-NICE 2010 Patients WITH NEW SYMPTOMS of HF should have NTproBNP measurements and referred to the Diagnostic clinic if NTproBNP>400 ng/l These patients should have an echocardiogram and a specialist opinion

5. The frequency of NP testing in Sheffield Since 2012, and every month there has been a 6.2% increase in the number of tests. Interestingly the rise was mainly at the expense of rising negative tests (<400) Within the positive tests, the rise has been mainly in those with NTproBNP 400-2000 Not all those with a positive tests are being referred to Cardiology

6. The HF Diagnosis and Management Clinic - Workload

7. The outcomes of HF diagnostic clinic HFPEF 33% HF-LVSD (HFREF) 31% No HF 24% Pulmonary hypertension 5% Valve problems leading to HF 3% Other types of HF 3% (e.g RV systolic impairment)

8. Update on the diagnosis and management of HF Dr Abdallah Al-Mohammad, MD, FRCP(Edin), FRCP(Lond), FESC Consultant Cardiologist, Sheffield Teaching Hospitals NHS Foundation Trust PLI 18 11 2015 Sheffield

9. Diagnosis The patient has symptoms of HF probably with signs if one looked for them The patient with no prior therapy will have a raised NTproBNP The diagnosis can not be made without imaging the heart

10. HF-LVSD: HFREF The type of HF that affects less than 50% of the HF patients in the community There is evidence based therapy Unless the patient has a contra-indication, all patients with HFREF should be treated with ACEi and a Beta blocker proven to be effective in HF (Bisoprolol, Carvedilol, Metoprolol, Nebivolol)

11. HFREF 2 Once on the maximum tolerated doses of ACEi and a Beta blocker effective in HF, the patients who remain symptomatic should be commenced on an aldosterone antagonist (spironolactone or eplerenone) The combination of ACEi and AA, is usually safe provided close monitoring of the renal function is adhered to

12. HFREF 3 Only when the side effects of ACEi are intolerable should you switch to an ARB. If the cough did not disappear, please ask yourself two questions: a. Was ACEi responsible here? B. Should I continue to deprive the patient from ACEi?

13. HFREF 4 The black patient with SBP>125 who is already on optimal therapy with ACEi/BB/AA should be considered for Hydralazine and Nitrates If the heart rate remained >75 bpm, the patient is in sinus rhythm and no further uptitration of BB is possible, then consider adding ivabradine 2.5 mg bd, and uptitrate to no more than 7.5 mg bd (Keep HR>60bpm) Digoxin

14. Monitor Frequent U+E when uptitrating U+E at 1,4,8,12 weeks and then every 3 months; if on AA and ACEi/ARB 6 monthly: Cognition/Psychology/U+E/ECG/General status The ECG is to look for ? AF, and the width of QRS >130 m sec especially if LBBB: ?CRT

15. HFPEF Treat the co-morbidities especially hypertension. Consider treatment of ischaemia and better diabetes control Diuretics for fluid overload Spironolactone 12.5 mg may reduce HF hospitalisation In these patients there is no indication to add ACEi/BB routinely unless for another reason

16. HF due to significant valve disease An indication for cardiology interventions, usually surgical and increasingly TAVI for elderly patients with severe AS

17. HF due to pulmonary hypertension Control of fluid overload with diuretics with or without spironolactone ?Anticoagulate Referral of the very few to the Regional Pulmonary Hypertension unit

18. LCZ696 LCZ696 is a combined Valsartan and Neprilysin inhibitor that was proven in HFREF to be superior to ACEi Currently being assessed in a TA by NICE Implications could be huge and once licensed we need to carefully consider what needs to be done

19. ICD Treat ventricular arrhythmia in patients with LVEF<35% Primary prevention of arrhythmia in patients with LVEF<35%

20. CRT-P/D When the patient with HFREF and LVEF 150 msec; or if QRS 130-150 with other supportive evidence of dys- synchrony CRT CRT-D

21. THANK YOU A Al-Mohammad