Download 4 Decisions Driving Growth - Croydon Health Services NHS Trust

Diagnosing Heart Failure
Sanjay Kumar
Lead Consultant Cardiologist
Grace Williams
Lead Heart Failure Specialist Nurse
Croydon Health Services NHS Trust
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Overview
• Role of BNP
• Role of Echo
• One Stop Heart Failure Clinic
• When to refer to secondary care
Role of BNP
“Rule-out” test for HF
Diagnosis:
• typical history
• physical signs
• evidence of an underlying cause (12 lead ECG, CXR, echo)
B-Natriuretic peptides:
• Released by stretched ventricular myocytes
• Homeostatic mechanism - decrease SVR, cause natriuresis (sodium and water loss)
• N-terminal (NT-)proBNP has long half-life (good diagnostic test), but 100% renal
clearance (high in CKD)
In patients presenting with SOB, for diagnosis of HF:
• 90% negative predictive value at cut-off BNP<100ng/l
• High BNP>500ng/l has 90% positive predictive value
• Intermediate levels - consider other causes e.g. AF, valves, ACHD, IHD (especially with
LV dysfunction), cor pulmonale, pulmonary HT, renal failure
Role of BNP
“Rule-out” test for HF
• “Negative” BNP in an untreated patient makes a diagnosis of heart failure
unlikely (high negative predictive value)
• Elevated BNP does not distinguish between heart failure due to left
ventricular systolic dysfunction (LVSD) and heart failure with preserved left
ventricular ejection fraction (HeFPEF).
Role of BNP
Like cardiac enzymes, BNP levels are dynamic
Fall with…
Rise with…
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Obesity
Diuretic therapy,
ACE inhibitors, ARBs
Aldosterone antagonists
Beta-blockers
Left ventricular hypertrophy
Cardiac ischaemia
Tachycardia
High right ventricular pre-load
Hypoxaemia [including PE]
Renal dysfunction [GFR <60 ml/min]
Sepsis
COPD
Diabetes,
Old age
Hepatic cirrhosis
Role of BNP
NICE CG108 (2010)
Management of CHF in adults in primary and secondary care
Key priorities for implementation
• Measure serum natriuretic peptides (B-type natriuretic peptide [BNP] or
N-terminal pro-B- type natriuretic peptide [NTproBNP]) in patients with
suspected heart failure without previous MI.
• Because very high levels of serum natriuretic peptides carry a poor
prognosis, refer patients with suspected heart failure and a BNP level
above 400 pg/ml (116 pmol/litre) or an NTproBNP level above 2000 pg/ml
(236 pmol/litre) urgently, to have transthoracic Doppler 2D
echocardiography and specialist assessment within 2 weeks.
Role of BNP
NICE CG108 (2010)
Management of CHF in adults in primary and secondary care
Key priorities for implementation
• Refer patients with suspected heart failure and previous myocardial
infarction (MI) urgently - echo and specialist assessment within 2 weeks.
• Measure serum natriuretic peptides (BNP or NTproBNP) for suspected
heart failure without previous MI.
• If BNP levels are “high” (BNP >400 pg/ml (116 pmol/l) or NTproBNP >2000
pg/ml (236 pmol/l)) – echo and specialist assessment within 2 weeks.
• If BNP levels are “intermediate” (BNP 100-400 pg/ml (29–116 pmol/l) or
NTproBNP 400-2000 pg/ml (47–236 pmol/l) – echo and specialist
assessment within 6 weeks.
Role of Echocardiography
Cause of clinical syndrome...including non-cardiac causes
Determines which treatments to offer
Role of Echocardiography
LVSD or HeFPEF? Implications for prognosis and treatment options
Evidence of old MI
LV hypertrophy? specific patterns e.g. ASH or apical HCM?
Valvular heart disease –
primary cause of HF?
or a consequence of adverse remodelling?
Right ventricular involvement (excludes hypertensive myopathy)?
Pericardial disease e.g. constriction, effusion?
Restrictive myopathy?
Pulmonary hypertension?
Direct Access Echocardiography
•
http://www.cress.bics.nhs.uk/health-professionals/referral-supportdirectory/c/direct-access-echocardiography
Community One-stop Heart Failure Clinic
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Echocardiogram performed on the day of the consultation, so diagnosis confirmed
or refuted immediately
http://www.cress.bics.nhs.uk/health-professionals/referral-supportdirectory/c/cardiology-services/
Heart Failure
• An integrated approach to provision of
services is fundamental to the delivery of
high-quality care to adults with chronic heart
failure.
• Croydon Clinical Commissioning Group
• Pathway diagnosing Heart Failure
Community One-Stop Heart Failure Clinic
• Rapid access (within 2 weeks for high-risk patients, within 6 weeks
for others)
• Specialist review by Cardiologist and Heart Failure Nurse, with echo
at the same appointment, thereby providing early confirmation of
diagnosis
• Follow-on diagnostics/ specialist treatments planned
• Specific management plan communicated to GP
• Medicine optimisation, patient education, empowerment to enable
self-management provided by HFSN
• OSHFC referral form available via CReSS (Croydon Referral Support
Service)
• http://www.cress.bics.nhs.uk/health-professionals/referralsupport-directory/c/cardiology-services/
One Stop HF Clinic
• 2 clinics per week in community locations (Tuesday
at Purley Hospital, Thursday at Shirley Clinic)
• Currently being led by Dr Silvia Gianstefani
(Consultant Cardiologist in Imaging)
• Locum dedicated Heart Failure Consultant starting
3rd August 2015 – Dr Brian Noronha – to be followed
by substantive appointment
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HF Coding
Congestive heart failure G580
Heart Failure G58
Right heart failure G580-2
Acute congestive heart failure G5800
Acute heart failure G582
Congestive heart failure due to valvular disease G5804
Heart Failure with preserved ejection fraction G583
Left ventricular failure G581
Echocardiogram shows left ventricular systolic dysfunction 585f
Echocardiogram shows left ventricular diastolic dysfunction 585g
Chronic Cor Pulmonale G41z-1
Preserved LV G583
Nice Quality statement 5
• People with chronic heart failure are offered
personalised information, education, support
and opportunities for discussion throughout
their care to help them understand their
condition and be involved in its management,
if they wish.
Role of HF Nurse in OSHFC
• Provide British Heart Foundation booklet , Traffic light’s
management tool, Personal management plan, contact
details
• Follow up post OSHFC includes - Medication titration to
target/optimal doses, Symptom monitoring
• …….then transfer care back to GP with long term
management plan and open re-referral (self or GP) if
HF symptoms deteriorate………
How to refer to the IHFNS
• http://www.cress.bics.nhs.uk/healthprofessionals/referral-supportdirectory/c/integrated-heart-failure-nursespecialist-service/
Cardiology Advice Service
• Cardiology advice Service available Monday to
Friday except Wednesdays
• Would prefer information via email on
[email protected]
but fax is acceptable
• http://www.cress.bics.nhs.uk/healthprofessionals/referral-supportdirectory/c/cardiology-services/
When to refer to secondary care
• GP Traffic Lights
• NICE QS statement 9, monitoring stable
chronic heart failure, 2011
• http://www.cress.bics.nhs.uk/healthprofessionals/referral-supportdirectory/c/integrated-heart-failure-nursespecialist-service/
GP Re-Referral Information to the Integrated Heart Failure Nurse Service
GREEN ZONE
Symptoms well controlled
Manage patient in the
General Practice
Stable Heart Failure
• No increased shortness of breath
• No increased swelling of feet, ankles legs or stomach
• No chest pain
• No weight gain of more than 2-3 pounds (1Kg) in 2-3 days, (it may change by
1 to 2 lbs on some days). Continue on daily weights and 1.5Litre/24Hr fluid
restriction
Ensure patient has 6 monthly reviews which should include repeat blood test
including Renal function, FBc, LFTs, TFTs, Weight/Fluid status, Sitting and Standing
Blood Pressure and Pulse. (HF Quality Standards 9, 2011)
YELLOW ZONE
Exacerbation of Heart Failure: Change in NYHA Status
Contact HF nurse to
discuss concerns on
020 8274 6416
or 020 8401 3000 bleep 772
• Increased shortness of breath
• Weight gain over last 2-3 days - ask patient to continue daily weights.
• More swelling of feet, ankles, legs or stomach
• Fatigue
Consider using Trigger
Tool for EoL (See attached)
• Has a productive cough with frothy white sputum
• Postural drop
• Loss of appetite/cachexia
• Have diarrhoea &vomiting – In view of dehydration
• Orthopnoea and Paroxysmal nocturnal dyspnoea
Please ensure the patient has had up-to-date renal function and check vital
signs. Please consider increase in diuretic therapy for symptom management.
RED ZONE
Consider need for hospital
admission
Acute Exacerbation of Heart Failure: Change in NYHA Status
Or Advance Care Planning

Resus status
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GSF register
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CMC register

Referal Palliative
Care/HF Nurse
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symptom
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management
• Breathlessness at rest
• Struggling to breathe - Orthopnoea and Paroxysmal nocturnal dyspnoea
• Increased fluid overload
• Palpitations
• Faint /Syncope
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HFNS Contact details
We are available Monday – Friday, 09.00hrs –
17.00hrs
Lennard Road Office
Telephone: 020 8274 6416 or 6152
Fax: 020 8274 6174
Croydon University Hospital
Telephone: 020 8401 3000 Ext. 4413
Contact via switchboard 020 8401 3000, bleep 772
Cardiology Dept. Contact details
• Telephone: 0208 401 3000 ext. 4487
• Fax: 0208 401 3022
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Reference
• http://www.nice.org.uk/guidance/qs9/chapter
/List-of-statements