1. The Waikato Integrated Heart Failure Service (WIHFS) Debbie Chappell CNS Heart Failure Taumarunui/Te Kuiti/Otorohanga/Te Awamutu

2. The Waikato Integrated Heart Failure Service Team  HF CNSs: Julie Jay, Eileen Gibbons, Karyn Haeata,Debbie Chappell, Simona Inkrot, Catherine Callagher  Cardiologists: Mark Davis, Gerry Devlin, Raewyn Fisher  Sonographers

3. HF in Aotearoa/NZ  2 % Heart Failure prevalence in Western societies  HF Incidence is rising with an ageing population and the improved treatment and survival of heart disease  Median survival of 3.5 years after initial HF admission in NZ  One-year HF mortality rates after initial hospital admission are between 25 and 35%  Maori patients admitted with HF are significantly younger than NZ European: mean age 62 vs. 78 years McMurray et al., 2012; Wasywich et al, 2010; Schaufelberger et al., 2004; Wall et al., 2012

4. Refresher A&P

5. Heart Failure is a clinical syndrome where the heart is unable to pump blood at a rate required by the body, patients present with some or all of the following features:  Symptoms typical of heart failure (breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling) AND  Signs typical of heart failure (tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly) AND  Objective evidence of structural or functional abnormality of the heart at rest (cardiomegaly, third heart sound, cardiac murmurs, abnormality on the echocardiogram, raised natriuetic peptide concentration) Definition

6. Normal HF-REF HF-PEF

7. Some causes of heart failure Coronary artery disease Hypertension Valvular heart disease Cardiomyopathies Endocrine disorders-thyrotoxicosis Genetic conditions Congenital heart disease Inflammatory Chronic arrhythmias Also think of co morbidities – diabetes, obesity, COPD

8. Pathophysiology Compensatory mechanisms of acute heart failure Sympathetic nervous system activation Renin-angiotensin system activation LV remodelling OUTCOME: Vasoconstriction – Increased HR, SV leads to increased CO Attempt to maintain cardiac output and vital organ perfusion – heart, brain, kidneys

9. Maladaptation Compensatory mechanisms become “maladaptive” in chronic heart failure OUTCOME: -Excessive vasoconstriction -Increased afterload -Excessive salt and water retention -Electrolyte abnormalities -Arrhythmias

10. Investigations Observations – TPR BP (lying/standing), weight, height BMI ECG – old and new changes Bloods – CBC, U&E, Cardiac enzymes, NT-pro BNP, LFT, Cholesterol, TFT CXRay – old and new ECHO- normal EF >55%, moderate – severe HF<40%

11. Treatment Options – medical vs intervention Pharmacological - Diuretics -ACEi -Beta-blockers -Other drugs Non pharmacological -fluid management -nutrition -physical activity -smoking -psychosocial support -other factors

12. Case studies 75 year old female History incr SOBOE (getting worse) Bilateral pitting oedema JVP +2, chest clear History hypertension Dip stick, LFT, U&E NT pro BNP 400 pg/mL Refer - ECHO normal LV, elevated filling pressures, HFpEF Treatment options 49 year old male Bilateral oedema, pants tight Appetite depressed JVP normal, ascites, ? pulsatile liver Jaundiced Dip stick (bilirubin) LFT - abnormal NT pro BNP – normal Renal – normal Check ? Hepatitis, alcohol, blood transfusion

13. Aims of treatment / nursing role Improve symptoms – fluid restrict, daily weigh, medication Improve LV function – medication, medical intervention Improve exercise tolerance – moving, pacing themselves Improve patient education & self-management – HF booklet Decrease hospital admissions - improve survival End of life care

14. CNS led interventions for HF patients  Decreased hospitalisation, decreased number of events, readmissions and days in hospital  Improved survival  Cost effective  Improved self-care behaviour Stromberg et al., 2003; Phillips et al., 2005

15. Referral Criteria Inclusion: Patients with possible heart failure and/or at high risk for heart failure in the community, e.g. previous MI, family history of cardiomyopathy Patients readmitted for heart failure within 3 months Heart failure patients with significant co-morbidities affecting optimisation of treatment “Shared care” for end stage/palliative care Exclusion: Lack of consent from patient Acute coronary syndrome Patients already under the care of a cardiologist, unless referred by this cardiologist (inclusion criteria must be satisfied) COMPONENTS OF WIHFS Specialist clinics (CNS and cardiologists), Home visits, Telephone care –Patient and family/whanau education: heart failure knowledge and self-care –Clinical monitoring –Titration of heart failure medications in consultation with GP and/or cardiologist Professional education/CME for other health professionals and community teams

16. Thank you Questions? Debbie Chappell – Taumarunui Te Kuiti/Otorohanga/Te Awamutu 0212419452 07 8785192