Download Heart Failure in Primary care

Heart Failure
in Primary care
Lucy McGurn
Sarah Green
Learning Objectives
a) Increased awareness of the scale of the problem
b) Improved knowledge of the most appropriate general
investigations
c) Confidence with drug management of heart failure
d) Increased awareness of non-pharmacological
interventions and their effectiveness
e) Improved understanding of when to refer on to
secondary care
Heart Failure
• Occurs when output of the heart is inadequate to meet the
needs of the body
• End stage of all diseases of the heart
• Prevalence 1-1.6% (10-20% >75yrs)
• Poor prognosis can be improved by early and optimal
treatment
• Increasingly important as population ages
• Causes – IHD, hypertension, valvular disease, alcohol,
hyperthyroidism
Mr Jones is an 78-year-old widower who has attended
your afternoon surgery because of increasing
shortness of breath and fatigue on exertion. He says he
is struggling to play a whole round of golf.
He was last seen in his over-75 health check when it
was noted that his BP was 160/80 with a BMI of 29.8,
but otherwise there were no problems identified.
He has been a lifelong smoker and his diet has been poor
since his wife died of breast cancer 4 years ago.
What do you think is wrong with Mr Jones?
Making the diagnosis - Symptoms
LVF (back pressure into pulmonary system)
SOB on exertion
Nocturnal cough
Orthopnoea
Wheeze
Reduced exercise tolerance
PND
Lethargy
RVF (back pressure into peripheral circulation)
Ankle oedema
Fatigue and wasting
Increased weight
Nausea and anorexia
Abdo pain due to hepatomegaly
CCF (failure of both ventricles)
(Remember to ask about chest pain and palpitations)
New York Heart Association Classification of
Heart Failure
Class I - No limitations
Ordinary physical activity does not cause undue fatigue dyspnoea or palpitation
(asymptomatic left ventricular dysfunction)
Class II - Slight limitation of physical activity
Such patients are comfortable at rest. Ordinary physical activity results in
Fatigue, palpitation, dyspnoea or angina pectoris (symptomatically‚ mild heart failure)
Class III - Marked limitation of physical activity
Although patients are comfortable at rest, less than ordinary physical activity will lead to
symptoms (symptomatically‚ moderate heart failure)
Class IV: Inability to carry on any physical activity without discomfort
Symptoms are present even at rest. With any physical activity increased discomfort is
experienced (symptomatically‚ severe heart failure)
You examine Mr Jones – what might you find??
Making the diagnosis - Signs
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Cachexia and muscle wasting
Tachypnoeic +/- cyanosis
Tachycardia +/- gallop rhythm
Cardiomegaly and displaced apex
Right ventricular heave
Raised JVP
Basal creps +/- effusions +/- wheeze
Ankle oedema
Hepatomegaly
Ascites
When you examine Mr Jones you find signs of left
and right heart failure.
What further investigations do you want??
Making the diagnosis - investigations
a) Weight – good for trend
b) BP
c) ECG – IHD changes, LVH, slow AF
d) Bloods – U&E, TFT, LFT, FBC, Lipids, Gluc, natriuretic peptides
e) CXR
f) Urinalysis
g) PEFR/spirometry – if uncertain about Dx
Making the diagnosis –NICE Guidance
•
New guidance 2010 replacing 2003
•
Good algorithm on diagnosis of heart failure
in quick reference guide
•
If previous MI refer
•
If no previous MI then measure natriuretic
peptides
You measure Mr Jones BNP when comes back at
256 pg/ml
What do you do next? – follow NICE algorithm
When would you refer to secondary care – think
about the patients you see in your practice with
heart failure.
When to refer to specialist
multidisciplinary team?
a)
b)
c)
d)
e)
f)
Initial diagnosis of heart failure
Severe HF (class IV)
HF not responding to treatment
HF due to valve disease
HF that can’t be managed at home
Women thinking of pregnancy
g) Suspected HF and previous MI – urgent 2/52
Mr Jones attends hospital and has an echo
showing a reduced ejection fraction. The
Cardiologist starts him on 2 medications what
might they be?
Mr Jones attends hospital and has an echo
showing a reduced ejection fraction. The
Cardiologist starts him on 2 medications what
might they be?
Combination of an ACE-inhibitor and β-blocker
Treatment of heart failure – ACE Inhibitors
- Captopril, Enalapril, Lisinopril, Ramipril
- Start low and titrate up every 2/52
- Monitor U&E, eGRF & BP – at initiation/after
increase (expect small increases)
- if suspect valve disease don’t start
- use angiotensin II receptor antagonist if SE’s
(valsartan, candesartan, losartan)
Treatment of heart failure - βblockers
- Carvedilol, bisoprolol (short-acting)
- Good for HF due to LVSD
- Start low and titrate up every 2/52
- monitor HR, BP, clinical status
- can give to elderly, PVD, diabetes, interstitial
pulmonary disease COPD (without reversibility)
- don’t just stop as get rebound – ischaemia/arrythmias
You managed to get him stable on his medications with
initial frequent monitoring. He then remains well for the
next few years with 6 monthly checks.
Mr Jones returns to see you with worsening ankle oedema
and increasing SOB. He says he has had to stop playing golf
and is even having difficulty managing the hill up to the
corner shop.
What is his NYHA class now?
What drug might you add in?
Treatment of heart failure – diuretics
•
Loop (furosemide) or thiazides
(bendroflumethiazide)
•
Use minimum effective dose to control
congestive symptoms and fluid retention
•
Monitor for hypokalaemia
What else could you recommend??
Lifestyle and Rehabilitation
Educate – about the disease, current/expected
symptoms, need for Rx, prognosis
Discuss ways to make life easier – e.g. Benefits,
mobility aids, blue badge, social services
assessment for extra help
Diet – adequate calories, low salt, lose weight if
obese, restrict alcohol
Lifestyle and Rehabilitation
Lifestyle measures – smoking cessation, regular
exercise
Restrict fluid intake – 1.5-2 litres/day
Vaccination – pneumococcal + annual influenza
Assess for depression
You are asked to do a home visit to see Mr Jones as he rang
earlier saying his breathing was a bit worse than usual this
morning.
On arrival at his house it takes Mr Jones at least 5 minutes
to answer the door. He is acutely short of breath and is
having difficulty speaking in full sentences. He mentions
some tightness in his chest.
What may have happened??
What would you check??
You are asked to do a home visit to see Mr Jones as he rang
earlier saying his breathing was a bit worse than usual this
morning.
On arrival at his house it takes Mr Jones at least 5 minutes
to answer the door. He is acutely short of breath and is having
difficulty speaking in full sentences. He mentions some tightness
in his chest.
What may have happened??
What would you check??
You confirm fast AF with gross pulmonary oedema and ring for
an ambulance.
Atrial Fibrillation
• Can be difficult to know if AF is the cause or an
effect of heart failure
• Digoxin used as improves ejection fraction as well as
decreasing hospital admissions
• Increasing prevalence with worsening heart failure
Class I – 4%
Class II -10-26%
Class III – 20-29%
Class IV – 50%
Mr Jones has 4 further hospitals admissions over
the next few months. He now has home care going
in twice a day.
The district nurse asks you to go and see him as
she feels he is getting worse again.
What issues should you raise?
Longterm care and palliation
Poor prognosis - progressive deterioration to death
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50% die suddenly – probably due to arrhythmias
Mild/Moderate HF 20-30% 1yr mortality
Severe HF >50% 1yr mortality
Make use of specialist heart failure nurses
Involve palliative care
Think about resuscitation status
References/Resources
• Oxford Handbook of General Practice, Simon,
Everitt and Kendrick, Oxford University,
2005
• Chronic Heart Failure – Quick reference
guide, NICE, Aug 2010
• E-learning module – doctors.net
• British Heart Foundation Website