1. Chronic heart failure
By Vishal Patel GPVTS1

2. Objectives Definition Classification Types Diagnosis Management
Referral

3. Definition Efficiency of the heart pump is impaired Structural
Functional
Around 900,000 people in the UK have heart failure
Almost as many have damaged hearts but, as yet, no symptoms of heart failure
Both the incidence and prevalence of heart failure increase steeply with age, with the average age at first diagnosis being 76 years

4. Common causes in UK
CAD
HTN, MI, cardiomyopathy, valvular, arrhythmias

5. Q) How many people have HF in the UK?
B – 500,000
C – 900,000
D – 1.2 million

6. Q) How many people have HF in the UK?
B – 500,000
C – 900,000
D – 1.2 million

7. 900,000 have HF
Average 30 patients/GP

8. Presenting symptoms Asymptomatic Common symptoms
SOB, oedema, fatigue
Incidence & prevalence increase with age
76 years
Around 900,000 people in the UK have heart failure
Almost as many have damaged hearts but, as yet, no symptoms of heart failure
Both the incidence and prevalence of heart failure increase steeply with age, with the average age at first diagnosis being 76 years

9. Q) What percentage of patients die within the first year of diagnosis?
B 10 – 20%
C 20 – 30%
D 30 – 40%

10. Q) What percentage of patients die within the first year of diagnosis?
B 10 – 20%
C 20 – 30%
D 30 – 40%

11. Poor prognosis 30 - 40% mortality in 1st year
<10% per year thereafter

12. Classification NYHA
New York Heart Association Functional Classification

14. Types of HF Two types Left ventricular systolic dysfunction (LVSD)
Reduced EF
Impaired contraction
Preserved EF
Impaired left ventricular relaxation
Heart failure due to left ventricular systolic dysfunction (LVSD)
This is caused by impaired left ventricular contraction, and is usually characterised by a reduced left ventricular ejection fraction.
Heart failure with preserved ejection fraction (HFPEF)
This is usually associated with impaired left ventricular relaxation, rather than left ventricular contraction, and is characterised by a normal or preserved left ventricular ejection fraction.

15. Diagnosis/Investigations
ECG, CXR
Bloods test: FBC, U&E, eGFR, TFT, LFT, lipids, glucose, urinalysis, peak flow/ spirometry
Serum natriuretic peptides
(B-type natriuretic peptide [BNP] or
N-terminal pro-B-type natriuretic peptide [NTproBNP])
Without previous MI

16. Q) For patients with i) previous MI and
Q) For patients with i) previous MI and ?heart failure or ii) raised BNP When should this patient be assessed by a specialist?
A – 2 weeks
B – 4 weeks
C – 2 months
D – routine referral

17. Q) For patients with i) previous MI and
Q) For patients with i) previous MI and ?heart failure or ii) raised BNP When should this patient be assessed by a specialist?
A – 2 weeks
B – 4 weeks
C – 2 months
D – routine referral

18. Previous MI & suspected HF, refer for ECHO and specialist assessment within 2 weeks.

19. Diagnosis/Investigations
BNP hormone
Released in response to changes in the heart
Can be used to diagnose or monitor HF
BNP/NT-proBNP
Not interchangeable

20. Q) What level of BNP warrants a referral?
C >400
D >500

21. Q) What level of BNP warrants a referral?
C >400
D >500

22. Diagnosis/Investigations
BNP >400 or NNTproBNP >2000
Urgent referral, ECHO, specialist assessment within 2 weeks
Levels lower
ACEI, b blockers, ARB’s, aldosterone antagonists
Levels higher
LVH, hypoxaemia, renal dysfunction, COPD, sepsis, diabetes, >70 years old, liver cirrhosis.

23. ECHO

24. Q) What drug type is not the first line treatment for heart failure?
A – Aldosterone antagonists
B - B blockers
C - Diuretics
D - ACE I

25. Q) What drug type is not the first line treatment for heart failure?
A – Aldosterone antagonists
B - B blockers
C - Diuretics
D - ACE I

26. Treatment LVSD HF preserved EF ACEI, beta blockers +/-Diuretics
Diuretics only

27. Treatment
Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure.
Lifestyle: stop smoking, stop alcohol,
Yearly flu vaccine
Pneumococcal vaccine
once

28. Aspirin in patients with HF &
Consider anticoagulants in patients with Hx VTE, LV aneurysm or intra cardiac thrombus
Aspirin in patients with HF &
CAD
Atherosclerotic arterial disease.

29. When to refer?

30. When to refer For the initial diagnosis of heart failure
the management of:
severe heart failure (NYHA class IV)
heart failure that does not respond to treatment
heart failure that can no longer be managed effectively in the home setting. 
Previous MI and signs of HF
2 weeks

31. Worsening / severe HF due to LVSD
Symptomatic despite:
ACE I and B blocker.
Worsening / severe HF due to LVSD
Despite on 1st and 2nd line meds
HF due to valvular disease

32. Q) How often should we monitor stable HF patients?
A - 3 monthly
B - 6 monthly
C - yearly
D - when the EMIS/SystmOne prompts me

33. Q) How often should we monitor stable HF patients?
A - 3 monthly
B - 6 monthly
C - yearly
D - when the EMIS/SystmOne prompts me

34. Q) How often should we monitor stable HF patients?
A - 3 monthly
B - 6 monthly
C - yearly
D - when the EMIS/SystmOne prompts me

35. Monitoring If stable, at least 6 monthly Bloods: U&E, eGFR
Medication review
a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status

36. References
Oxford handbook of General Practice 4th Edition

37. Questions?