1. Clinical Knowledge Summaries CKS Heart failure - chronic Diagnosis and initial management in primary care. Educational slides based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

2. Key learning points and objectives To be able to: oRecognise people with suspected heart failure (HF). oOutline how to investigate suspected HF. oDescribe why natriuretic peptides are measured and how they are used to decide on the urgency of referral. oExplain why referral to a specialist is required. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

3. Definition Heart failure (HF) - the ability of the heart to maintain the circulation of blood is impaired. HF with left ventricular systolic dysfunction. o Evidence of left ventricular systolic dysfunction (e.g. reduced left ventricular ejection fraction [LVEF] on echocardiography [echo]). o Accounts for a little more than half of the people with HF. HF with preserved ejection fraction (PEF). o Good contraction of the heart muscle on echo. o An LVEF of 45–50% or more is normal. o The usual cut off for PEF is 40-50% LVEF. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

4. Causes Conditions that damage heart muscle or limit its ability to function normally e.g. o Coronary artery disease (most common). o Hypertension (next most common). o Cardiomyopathies. Conditions that reduce cardiac output e.g. o Increased vascular resistance with hypertension. o Abnormal heart rhythm Conditions that result in a high cardiac output e.g. o Anaemia. o Thyrotoxicosis. o Septicaemia. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

5. How common is it? Prevalence increases with age. o 7% for people 75–84 years of age. o 20% for people 85 years of age or older. Accounts for: o 2% of all hospitalised bed-days. o 5% of all medical emergency admissions. Average GP will: o Look after 30 people with HF at any one time. o Suspect a new diagnosis of HF in 10 people annually. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

6. New York Heart Association (NYHA) HF classification Class I: asymptomatic left ventricular dysfunction is included: o No limitations. Ordinary physical activity does not cause fatigue, breathlessness, or palpitation. Class II: symptomatically “mild”. o Slight limitation of physical activity. Such people are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, breathlessness, or angina pectoris. Class III: symptomatically “moderate”. o Marked limitation of physical activity. Although people are comfortable at rest, less than ordinary physical activity will lead to symptoms. Class IV: symptomatically “severe”. o Inability to carry on physical activity with out discomfort. Symptoms of cardiac failure are present even at rest. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

7. Complications Arrhythmias – common at any stage. o Atrial fibrillation — prevalence increases with severity of HF. o Ventricular arrhythmias — common with dilated left ventricle and reduced LVEF. Depression o Occurs in up to one third of people with HF. Sexual dysfunction o Common – may be caused by HF or drugs (e.g. beta-blockers). Cachexia (wasting) – serious complication o Usually occurs together with severe dyspnoea and weakness. o Life expectancy is worse for people with cachexia and HF than that for most cancers. Sudden death – about half of HF deaths are related to sudden cardiac death. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

8. Prognosis Prognosis depends on the cause, age, comorbidities, and adherence to treatment. But, in general, the prognosis is poor: o 50% of people die within 4 years of diagnosis. o 40% of people admitted to hospital die or are readmitted within 1 year. o Younger people and people with no other medical problems do better. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

9. Prognosis Mortality rates are beginning to drop. Drug treatments and input from heart failure specialists have reduced mortality and morbidity, but Prognosis is consistently poor for people who receive suboptimal care. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

10. Cost of HF to the NHS Total annual cost of HF is around 2% of the total NHS budget: o70% of this is due to the costs of hospitalisation. Admissions are usually protracted (7-8 days). Readmissions are common: o1 in 4 patients are readmitted in three months. Co-morbidities account for a substantial proportion of admissions. The costs increase with disease severity. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

11. Suspecting HF Suspect HF if there are symptoms, signs, or risk factors for HF. Symptoms include: oBreathlessness (on exertion, lying flat, or on waking). oFatigue. oFluid retention (ankle swelling, abdominal swelling). Signs include: oLaterally displaced apex beat. oRaised jugular venous pressure. oEnlarged liver (due to engorgement). oThird or fourth heart sound (gallop rhythm). oTachycardia. oLung crepitations (persisting after coughing). oDependent oedema (legs, sacrum). Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

12. Suspecting HF Risk factors for HF include: oMyocardial infarction, coronary artery disease, or angina. oAtrial fibrillation. oDiabetes mellitus. oHypertension. oExcessive alcohol consumption. oPrevious cardiotoxic chemotherapy (e.g. doxorubicin, daunorubicin). oFamily history of heart failure or sudden cardiac death from cardiomyopathy at a young age. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

13. Differential diagnosis Conditions causing shortness of breath such as: oChronic obstructive pulmonary disease. oAsthma. oObesity. oVolume overload from renal failure or nephrotic syndrome. oAngina. oAnxiety. Conditions causing peripheral oedema such as: oDependent oedema that is not pathological, (e.g. prolonged inactivity). oNephrotic syndrome. oDrugs (e.g. calcium-channel blockers, NSAIDs). oHypoalbuminaemia. oVenous insufficiency. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

14. How to investigate? Measure natriuretic peptides: o B-type natriuretic peptide (BNP) Secreted from the heart wall especially when stretched or when the pressure within it increases. Increases renal excretion of sodium and water. Relaxes vascular smooth muscle, which leads to vasodilation. o N-terminal pro-BNP (NT-proBNP) Inactive prohormone of BNP. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

15. Why use natriuretic peptides? Natriuretic peptides help to determine: o The likelihood of the presence of heart failure. o The need for referral for specialist assessment and confirmation of the diagnosis by echocardiography. o The urgency of the referral. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

16. Why use natriuretic peptides? Good evidence that *: o Elevated levels do not confirm the diagnosis of heart failure, but o Normal levels rule the diagnosis out. o The accuracy of both tests (BNP and NT-proBNP) are similar. o BNP has a greater diagnostic accuracy than ECG. * Based on a Health Technology Appraisal Mant, J. (2009) Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. 13(32), 1-207

17. How to investigate If no previous MI: oMeasure the natriuretic peptide level, using either B-type natriuretic peptide (BNP), or N-terminal pro-BNP. If previous MI: oDo not measure the natriuretic peptide level. oRefer (within 2 weeks) for specialist assessment and echocardiography. oIf HF is suspect the prognosis is poor. For everyone (regardless of MI status) also do 12- lead electrocardiography. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

18. How to investigate Look for aggravating factors and exclude other conditions using: o Chest X-ray. o Blood tests; U & Es, creatinine, FBC, thyroid function, LFTs, glucose, lipids, and urinalysis. o Lung function tests (peak flow or spirometry). Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

19. If natriuretic peptides not measured Where it is not possible to measure natriuretic peptides: oUse an ECG to decide if referral is required. A normal ECG can help rule out HF, but o The presence of any abnormality does not help to rule in the diagnosis of heart failure. o About 1 in 10 people with HF have a normal ECG. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

20. Initial management NICE recommends referral for specialist assessment and echo to confirm the diagnosis as: oThe diagnosis should not be based on the results of echocardiography alone. oIt is important to identify the type and severity of the abnormality responsible for heart failure. While awaiting confirmation of the diagnosis: o Consider stopping any drugs that may affect the person’s heart failure (e.g. NSAIDs or calcium channel blockers). Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

21. Role of echocardiography Excludes valve disease. Assesses systolic and diastolic function. Detects intracardiac shunts. Measures ventricular function - (e.g. LVEF). oAn LVEF of 45–50% or more is normal. oMost people with HF have a reduced LVEF. For people with preserved ejection fraction: oEcho shows normal or only mildly abnormal left ventricular systolic function (LVEF >= 45–50%). oMay be evidence of diastolic dysfunction. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

22. Initial management Refer within 2 weeks if: o Previous MI (prognosis is poor). o No previous MI but high levels of natriuretic peptide. B-type natriuretic peptide (BNP) level above 400 pg/mL (116 pmol/L), or N-terminal pro-B-type natriuretic peptide (NT-proBNP) level above 2000 pg/mL (236 pmol/L). o Severe symptoms. o Pregnant. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

23. Initial management Refer within 6 weeks: o If no previous MI and raised levels of natriuretic peptide: BNP level between 100–400 pg/mL (29-116 pmol/L), or NT-proBNP level between 400–2000 pg/mL (47– 236 pmol/L). o If natriuretic peptide levels are normal and: o Clinical suspicion of HF persists and the person is obese or taking drugs which lower natriuretic peptide levels. o Another condition is suspected which requires referral. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

24. Initial management Where it is not possible to measure natriuretic peptide levels, refer if: o The ECG is abnormal, or o The ECG is normal, but there is still a strong suspicion of heart failure. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

25. Management awaiting referral If possible - stop medicines affecting the person’s heart failure, for example: oSome calcium channel blockers – verapamil and diltiazem, oNSAIDs. If symptoms need treatment (but not admission), start a loop diuretic such as: o Furosemide 20 mg/day to 40 mg/day. If higher doses are needed: o Check adherence. o Review the differential diagnosis o Seek specialist advice. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

26. Summary About 50% of people die within 4 years of having a diagnosis of HF. Treatment with an ACE inhibitor and beta-blocker significantly improves mortality and morbidity. To confirm the diagnosis refer for specialist assessment and echo. Refer within 2 weeks if: oNo previous MI but high levels of natriuretic peptide. oThere is a previous MI - no need to measure natriuretic peptides, prognosis is poor. oSevere symptoms or pregnant. Refer within 6 weeks if no previous MI and raised levels of natriuretic peptide. Reconsider diagnosis if natriuretic peptides are not raised. If unable to measure natriuretic peptides use results of the 12 lead ECG; refer if o The ECG is abnormal, or o The ECG is normal, but there is still a strong suspicion of heart failure. While awaiting referral start a loop diuretic to manage symptoms.