Download Chronic Heart Failure Clinical Guideline No. 5 NICE – July 2003

Helen Williams
Alison Bentley
Consultant Pharmacist for CVD
South London
Clinical Lead for CVD
Lambeth and Southwark CCGs
Heart Failure Specialist
Nurse
Croydon Health Services
NHS Trust
www.nice.org.uk
NICE 2010 CG 108
Chronic Heart Failure
http://www.nice.org.
uk/CG108
And ivabradine….(NICE 2012)
www.nice.org.uk
Incremental Benefits with HF Therapies
(Cumulative % Reduction in Odds of Death at 24 Months)
-28% to -49%
P<0.0001
-54% to -71%
P<0.0001
-68% to -81%
P<0.0001
-75% to -86%
P<0.0001
Fonarow GC, et al. J Am Heart Assoc. 2012;1:16-26.
-77% to -88%
P<0.0001
-72% to -87%
P<0.0001
Incremental Benefit with HF Therapies
(Cumulative % Reduction in Odds of Death at 24 Months
Associated with Sequential Treatments)
+20% to -68%
P=0.1566
-43% to -91%
P<0.0001
-70% to -96%
P<0.0001
Fonarow GC, et al. J Am Heart Assoc. 2012;1:16-26.
HF patients on ACEI = 22%
HF patients on BB = 16%
www.gpcontract.co.uk

People with chronic heart failure due to left
ventricular systolic dysfunction are offered
angiotensin-converting enzyme inhibitors (or
angiotensin II receptor antagonists licensed
for heart failure if there are intolerable side
effects with angiotensin-converting enzyme
inhibitors) and beta-blockers licensed for
heart failure, which are gradually increased
up to the optimal tolerated or target
dose with monitoring after each increase
www.nice.org.uk

What are the barriers to ACEI and BB
initiation?
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What are the barriers to dose titration?
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What additional support do GPs need?

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.
www.nice.org.uk
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Diet
Salt intake
Exercise
Fluid restriction
Alcohol
Smoking
Substance misuse
Sexual activity
Driving / air travel
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Personal management plan
Heart failure traffic lights:
http://www.cress.bics.nhs.uk/health-professionals/referralsupport-directory/c/integrated-heart-failure-nursespecialist-service/
Self manage diuretics
Access useful websites:
BHF: www.bhf.org.uk
ESC:
www.heartfailurematters.org
Cardiomyopathy Association: www.cardiomyopathy.org
Arrhythmia Alliance: www.arrhythmiaalliance.org.uk
Limitations to uptitration:
Beta-blockers
ACE inhibitors
 Symptomatic
 Symptomatic
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hypotension
Bradycardia
Evidence of reversible
airways disease
Tiredness / fatigue
Weight gain due to
increased congestion
Erectile dysfunction
hypotension
 Worsening renal
function (increasing
creatinine or potassium)
 Dizziness
 Persistent, intolerable
dry cough that interferes
with sleep - Uncommon
Case 1
 A 68 year old lady was seen 4 weeks ago by your partner.
 She complained of increasing shortness of breath on doing
her daily housework.
 She had no past history of serious illness, and she had
oedema, a raised JVP and orthopnoea at night.
 Her BP was 140/90.
 She was thought to have cardiac failure and was
admitted because of a tachycardia.
 The hospital discharge note says she had CCF and was
discharged on:
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

Aspirin
lisinopril 2.5mg daily
furosemide 40mg daily.
 There is a follow-up hospital appointment in 6 weeks time.
Questions
 What more information would you like?
 What should the GP’s follow-up management be?
 Who else would you involve in this patient’s
management?
Information…..
 ECHO results – EF
 ECG – rate and rhythm and QRS durations
 Admitted with a tachycardia (? No treatment!)
 NYHA class
 Underlying cause
 ?ischaemia / ?hypertension / valve disease
 Renal function or dysfunction
 BP
 Any relevant PMH on record
GP Management......
1.
2.
3.
4.
5.
6.
7.
Check BP, renal function, JVP / oedema
Dose titrate ACEi at 2 weekly intervals
Review diuretic dose
Check HR – ?add a beta-blocker
Lifestyle issues – salt, exercise, weight
If ischaemic cause – consider other CV risk factors
Check glucose – ensure no diabetes
Involvement of Others….
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Cardiology advice line
HFNS
Relatives / carers
Practice Nurse / community pharmacist
Dietician
Rehab service (if available)
Counsellor (if appropriate)
Benefits / social services support (if appropriate)
Local cardiac support group
Case Study 2
 A 63 year old male was being followed up in the heart
failure clinic. He complained of breathlessness on
mild exertion.
 He was taking the following medications:
 Frusemide 80 mg od
 Ramipril 10 mg od
 Spironolactone 25 mg od
 Bisprolol 10 mg od
 Aspirin 75 mg od.
 On examination the heart rate was 90 per minute and
regular.
 The blood pressure measured 86/60 mm Hg.
 The JVP was raised. The cardiac apex was displaced.
 Auscultation of the heart revealed an added third
heart sound. The chest was clear. There was no ankle
odema.
 Echocardiography showed a dilated left ventricle with
an ejection fraction of 25%.
Question……
 Which one of the following would you institute to
improve his symptoms?
 Refer for cardiac transplantation
 Add Hydralazine
 Increase the dose of loop diuretic
 Increase spironolactone
 Refer for ?ICD
 Refer for ?biventricular pacemaker
Case Study 3
JJ DOB: 04.03.1940 Cardiac / Heart Failure History
 Dilated cardiomyopathy of ischaemic aetiology.
 06.01.04 Echo:
 LV severely dilated, global hypokinesis / function severely
reduced. RV – severely reduced function. EF = 25- 35%
 Mild MR – why might this patient have MR? how should
it be managed?
 Other Medical History
 Asthma since childhood, severe airflow obstruction, Chronic
obstructive airways disease - 4 yr history
 Right carotid endartrectomy 1996
 Impaired fasting glucose, reviewed in diabetic dept who advise diabetic
diet and 6 monthly HbA1c
 Angina
 Main problems are:
 pain in knees limiting mobility
 inability to lose weight but felt that the diet outlined by
dietician was not achievable
 not sleeping well
 He is not aware of palpitations, no pre syncope,
uses 1 pillow but often sleeps in chair, no PND.
 On examination - JVP normal, no cardiac heave,
pulse of normal and character, no dependent
oedema, no respiratory crackles.
 NYHA class III (unable to determine how much
is heart failure related)
 HR 92 bpm; BP 127/82; Weight 117.2 kg
 Current Medication…..
 Ramipril 5mg bd
 Any comments on his
drug therapy?
 Frusemide 80mg om
 Spironolactone 25mg daily
 Aspirin 75mg daily
 Would you consider a
beta-blocker for him?
 Simvastatin 40mg on
 Isosorbide mononitrate
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MR 60mg om
GTN spray
Atrovent
Formoterol
Fluticasone
Salbutamol inhalers
 This man is
complaining of
‘nipple pain’ what is
the likely cause?
What would you do
about it?
 How would you manage this patients arthritis?
 What lifestyle issues would you consider for him?
 Other primary care interventions to reduce his risks?
 How can you help him sleep?
ACE Inhibitors
Reduce mortality in HF by ~ 25 to 30%
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Initiate early in the disease in pts:
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–
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CONSENSUS-I, VeHFt-II, SOLVD, GISSI-3, AIRE
With or without symptoms of LV dysfunction
With reduced Ejection Fraction on ECHO (<40%)
Benefit established across all NYHA classes
Optimise dose (ATLAS)
Continue indefinitely
Managing ACE inhibitor therapy
 Start at low dose to avoid first dose hypotension
 Increase dose to maximum tolerated
 i.e. Rampril 10mg daily, lisinopril 20mg twice daily
 Monitor renal function and potassium
 Advise low K+ diet if potassium high
 Monitor BP - but can increase dose if sBP ≤ 90mmHg
 Symptomatic hypotension may limit dose titration
 Common side effects – cough, hypotension, rash
Beta-Blockers
 ~30% reduction in mortality (additive to ACE-I)
 Reduction in hopsitalisations
 US Carvedilol Trials, MERIT-HF, CIBIS-II, COPERNICUS
 Data in NYHA class II, III & IV HF
 Initiate in all patients with LV dysfunction - regardless of
whether or not symptoms persist
 Introduce in a ‘start low, go slow’ manner, assessing HR, BP
and clinical status after dose titration
 Withdrawal of beta-blockers has been shown to:
 increase risk of worsening heart failure
 increased risk of early death

Circulation 1989; 80, 551-563; AmHeartJ 1999; 137, 456 - 459
Offer BBs to….
 older adults
 patients with:
 peripheral vascular disease
 erectile dysfunction
 diabetes mellitus
 interstitial pulmonary disease and
 chronic obstructive pulmonary disease (COPD)
Beyond ACEI and BB…
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Add Aldosterone antagonist?
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Mortality benefits evident in clinical trials but generally sicker
patients – EF<30% in EMPHASIS HF and recent hosp admission
Multiple studies across the patient spectrum
Add ivabradine?
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Reduces hospitalisations and HF deaths in pts in sinus rhythm if
HR remains raised; despite optimal BB
BUT, only one study to support......)
ARB?
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Main effect in RCTs was reduced hospitalisations
Add hydralazine/nitrates?
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Mortality benefits in African Americans NYHA class III, but
poorly tolerated and heavy pill burden
EMPHASIS HF
(eplerenone)
Using Aldosterone Antagonists
 Dosing:
 25mg daily initially
 Increase to 50mg daily if remains symptomatic
 Reduce to 12.5mg daily if hyperkalaemia
 Key ADRs
 Hyperkalaemia (common esp with ACEI)
 Gynaecomastia
 Renal deterioration
 Drug withdrawal common
Heart Rate & Coronary Heart Disease
+46%
+38%
RR
major cardiovascular
events 2
Myocardial
Ischaemia
Myocardial
Infarction
RR
hospitalisation for fatal
or non-fatal MI 3
in patients with CAD and LVD
(Stable angina)
+34%
in patients with stable CHD
RR
cardiovascular death 3
Left Ventricular
Dysfunction
+37%
RR
Coronary
Artery Disease
likelihood of
ischemia 1
in patients with stable
coronary disease
Coronory
Atherosclerosis
in patients with CAD and LVD
A number of studies have
shown that patients with
heart rate
> 70 bpm
Chronic Heart
Failure
have increased risk of:
1. Andrews TC et al .Circulation 1993;88:92-100 / 2. Ho JE et al. TNT study - poster presented at the ACC 58th Annual Scientific Session, March 29-31, 2009. / 3. Fox K et
al. Lancet 2008; 372: 817-821 4/ Cardiovascular continuum adapted from Dzau et al. Circulation December 2006
Ivabradine – heart rate control
 SHIFT study (2010);
 6558 patients with resting HR > 70bpm
randomised to ivabradine or placebo
 Primary end-point - CV death or HF
hospitalisation
 Reduction in the primary end point from 29%
placebo to 24% Ivabradine arm – an 18% relative
risk reduction (ARR 5%, p<0.0001)
 Mostly due to reduced HF hospitalisation and
deaths due to HF
HF due to LVSD
Standard Regimen
 Diuretics (for symptom control)
 ACE Inhibitors to improve outcome
 Beta-blockers to improve outcome
+/ Spironolactone if more severe HF (Class III/IV)
 Or eplerenone if less severe HF (class II)
 (Or candesartan?)
 Ivabradine if HR remains >75bpm (licensed Jan
2012?)
Other Issues
 Polypharmacy
 Multiple therapies
 Co-morbidities
 Non-adherence
 Symptom control vs risk reduction
 Intentional vs non-intentional
 Health beliefs
Helen Williams
Alison Bentley
Consultant Pharmacist for CVD
South London
Clinical Lead for CVD
Lambeth and Southwark CCGs
Heart Failure Specialist
Nurse
Croydon Health Services
NHS Trust