1. Background, recognition and differentials. By Dr L Axten

2. Clinical Context 900,000 people affected by heart failure in the UK. About the same amount of patients again with damaged hearts and no symptoms as yet. Risk of heart failure greater in men but more women with HF. Incidence and prevalence rise with age- 1 in 35 aged 64-74 1 in 15 aged 75-84 1 in 7 aged 85 & over

3. Clinical Context Continued Prevalence of HF expected to rise due to the aging population, improved outcomes for those with IHD and better treatments for HF. Causes-previous MI, also associated with HTN & AF. Damage to heart structures-dilated cardiomyopathy.

4. Prognosis Poor 30-40% mortality in one year Thereafter mortality is 10% a year Prognosis has improved in the last ten years Younger patients do better, as do those without co- morbidities HF failure has a massive impact on quality of life and is associated with mood disorder

5. GP perspective On average a GP will have 30 patients on their list with HF A GP will have on average 10 new diagnosis per year Deprived areas have a higher incidence of HF GP consultations cost approx £45m a year With referral to OPD costing approx £35m a year Cost of community pharmacy being £129m a year

6. NHS perspective 1 million in-patient beds per day 5% of all admissions to MAU Hospital admissions for HF are expected to rise by 50% over the next 25 years Protracted hospital admission 7-9 days 1 in 4 readmissions in 3 months

7. Patients perspective Affect on quality of life Loss of earnings Mood disorders Physical limitation Many patients receive sub optimal treatment

8. Diagnosing heart failure What are the signs and symptoms of heart failure?

9. Diagnosing Heart Failure Signs and symptoms of HF are often non specific Common-breathlessness, during activity or at rest (PND or orthopnoea) Fatigue Exercise intolerance Fluid retention Non-specific symptoms of heart failure include nocturia, anorexia, abdominal bloating and discomfort, constipation, and cerebral symptoms such as confusion, dizziness and memory impairment Signs and symptoms do not correlate to the severity of heart damage

10. Diagnosing heart failure 2 Raised JVP has high predictive value for HF but is not often present Tachycardia, third heart sound, displaced apex beat are not significant to HF in isolation Lung crepitations Hepatomegaly

11. New York Heart Association Classification of heart failure Grade 1- No limitations. Grade 2- Slight limitations on physical activity. Ordinary activity results in breathlessness, palpitations, fatigue or angina. (Mild HF) Grade 3- Marked limitation of physical activity. Comfortable at rest although less than ordinary physical activity will lead to symptoms in grade 2. (Moderate HF) Grade 4- Inability to carry out physical tasks without discomfort. Symptoms present at rest. (Severe HF)

12. Differentials Many conditions present with symptoms similar to HF Obesity, chest disease, venous insufficiency, drug induced ankle swelling (calcium channels blockers), drug induced fluid retention (NSAID’s), Hypoalbuminaemia Intrinsic renal or hepatic disease Pulmonary embolic disease Depression and anxiety Severe anaemia or thyroid disease Bilateral renal artery stenosis