* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Heart Failure Presentation - Dorset County Hospital NHS
Survey
Document related concepts
Management of acute coronary syndrome wikipedia , lookup
Remote ischemic conditioning wikipedia , lookup
Lutembacher's syndrome wikipedia , lookup
Echocardiography wikipedia , lookup
Rheumatic fever wikipedia , lookup
Electrocardiography wikipedia , lookup
Coronary artery disease wikipedia , lookup
Cardiac contractility modulation wikipedia , lookup
Arrhythmogenic right ventricular dysplasia wikipedia , lookup
Quantium Medical Cardiac Output wikipedia , lookup
Heart arrhythmia wikipedia , lookup
Heart failure wikipedia , lookup
Antihypertensive drug wikipedia , lookup
Dextro-Transposition of the great arteries wikipedia , lookup
Transcript
Chronic Heart Failure GP Clinical update 11/11/09 Dr Paul Armitage GP Heart Failure Specialist, Dorset PCT Tracey Dare Heart Failure Nurse Specialist, DCH Chronic Heart Failure “There is no disease that you either have or don’t have – except perhaps Sudden Death or Rabies. All other diseases you either have a little or a lot of” Geoffrey Rose Chronic Heart Failure- setting the scene Common Costly Disabling Deadly Increasing 1-2%of the population 1-2% of NHS budget symptoms have large impact on quality of life mortality 30% at 12 months but improving steadily ageing population/more effective treatment for CHD What is Heart Failure – key facts Heart Pump Inefficiency – either primarily a disorder of filling or of emptying (Tinsley R Harrison, 1950) Most common cause is LV muscle damage Various conditions may predispose to, or cause, such muscle damage Guess who? Causes of Chronic HF (UK only – Fox et al, European Heart Journal 2001) Coronary Heart Disease Chronic hypertension Idiopathic Valvular dysfunction Cardiac arrhythmias Alcohol Other Undetermined 52% 4% 13% 10% 3% 4% 4% 10% Prevalence CHD increasing Ageing population Better CHD acute phase care Better CHF management West Dorset Population - prevalence estimate 4,500 (sex & age specific calculations, 2002) Incidence 1- 4 new cases per 1000 population each year Incident rate rises to more than 10 cases per 1000 in those aged 85 years and over Male:female = 2:1 West Dorset population - incidence estimate 330 new cases per year (sex & age specific calculations, 2002) Guess who ? Mortality Mild – moderate CHF – 20% at 1 year Severe - >50% at 1 year Survival all classes – 30% at 8 years 80% mortality in men within 6 years of diagnosis Class II – sudden death risk Health Service Use HF accounts for 5% of all hospital admissions Patients frequently admitted Bed occupancy average 20 days each admission £360 million (hospitalisations = 59.5%) Guess who? Why so difficult? Symptoms non-specific Clinical signs insensitive Definition of heart failure disputed Poor primary care access to cardiac investigations eg BNPs and echocardiography Conditions presenting with similar symptoms Obesity Chest disease Venous insufficiency in lower limbs Drug induced ankle swelling (calcium channel blockers) Drug induced fluid retention (NSAIDs) Hypoalbuminaemia Intrinsic renal or hepatic disease Pulmonary embolic disease Severe anaemia or thyroid disease Bilateral renal artery stenosis Symptoms – may not be terribly helpful! Shortness of breath on exertion Decreased exercise tolerance PND Orthopnoea Ankle swelling Guess who? Clinical signs The most specific signs are: – – – Laterally displaced apex beat Elevated JVP 3rd heart sound Less specific signs: – – – – Tachycardia Lung crepitations Hepatic engorgement Peripheral oedema Investigations 12 lead ECG Chest X-ray FBC, U&E, TFT, LFT, glucose, lipids, urinalysis, peak flow BNP where available Echocardiography (open access available locally) NB: If ECG is normal - it is very unlikely that the diagnosis is heart failure. Same for BNP Guess who? How useful is BNP? 96% as useful as a panel of cardiologists NB CTR on CXR is only 79% as useful as a panel of cardiologists (the gold standard was an expert panel diagnosis blinded to BNP results) Lancet 1997; 350:1349-53 To diagnose Heart Failure 3 things are essential: – – – 1. Patient 2. BNP 3. ECHO Awaiting new NICE guidelines (PCTs beware!) Guess who? CHF management Establish cause (angiography, CDM screen) and treat appropriately Evidence based pharmacological treatments (ACEi, Beta blockers, aldosterone antagonists) Device therapy (CRT-P, CRT-D) Self management/ lifestyle advice Heart Failure Services Liaison/ onward referrals (CKD team, PPM techs, arrhythmia nurse, Smoke Stop, Dieticians, Cardiac Rehab, pharmacists, Community Matrons, PC Team) ACE inhibitors HOPE = Heart Outcomes Prevention Evaluation Study CONSENSUS = Co-operative North Scandinavian Enalapril Survival Study SOLVD = Studies of Left Ventricular Dysfunction All grades of CHF unless specific contraindications Cautions – Significant renal dysfunction, bilateral renal artery stenosis, symptomatic/ severe asymptomatic hypotension, K+ supplements/ K+ sparing diuretics ACE inhibitors ACEi Starting dose Target dose Ramipril 2.5mg od 10mg od Lisinopril 2.5 – 5mg od 30-35mg od Enalapril 2.5mg bd 10-20mg bd Cardio-selective Beta blockers Undisputed evidence. Recommended in NICE guidelines – – – – Reduction in HF exacerbations Reduction in hospitalizations and bed days Improved symptoms/ NYHA class/ QOL Reduces mortality Beta blocker Trials CIBIS (1994) and CIBIS II (1999) (The Cardiac Insufficiency Bisoprolol Study) COPERNICUS (CarvedilOl ProspEctive RaNdomIzed Cumulative Survival) 2001 CAPRICORN (Effect of Carvedilol on outcome after myocardial infarction in patients with left ventricular dysfunction) 2001 SENIORS (Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with heart failure) Undisputed evidence from various studies Beta blockers Beta-blocker titration Bisoprolol 1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg Carvedilol 3.125mg BD, 6.25mg BD, 12.5mg BD, 25mg BD Nebivolol 1.25mg, 3.5mg, 5mg, 7.5mg, 10mg Aldosterone antagonists Consider for moderate to severe HF already on ACEi and loop diuretic – – – Spironolactone 25mg (increase to 50mg if necessary) Epleronone 25mg (increase as above) NB licensed for post MI only but consider for all patients if Spironolactone causes hormonal side effects NB Renal function monitoring Other pharmacological considerations Co-morbidities/ polypharmacy Compliance and understanding Blister packs Timely interface communication of drug dose changes Heart Failure Service Dorset County Hospital Set up in response to NSF 2001 Aim to optimise pharmacological therapy through series of out patient visits Patient education (BHF Heart Failure Plan). Medication concordance and treatment compliance. Monitoring Support & point of contact Interface link. Onward referrals Heart Failure Service Dorset County Hospital Clinic based intervention only x1 Full time HF Nurse Specialist GP Heart Failure Specialist x2 sessions per week Service provision includes:– – – Dorset County Hospital (x2 per week, plus some in-patient cover dependant on availability) Weymouth (x2.5 per week) Bridport Community Clinic (x1 per week) Heart Failure Service Dorset County Hospital Service population 229,836 Estimate 4,500 prevalence and 330 new patients per year Total referrals up to end of year 8 = 1489 (187 per year) 301 patients on present active caseload (as of 3/11/09) Heart Failure Service Dorset County Hospital Total number seen Combined HFNS & GPHFS Contacts 1600 1400 1200 1000 800 600 400 200 0 Series3 Series2 Series1 1 2 3 4 5 Year 6 7 8 Heart Failure Management Complex condition to manage Timely recognition/ diagnosis/ treatment of underlying causes results in best outcomes and more cost effective in the long run Open access echo service – direct route of referral to the HF service Pharmacological therapy is only part of the management but a big part of the heart failure service work Heart Failure Service Referrals from GPs can be accepted if the patient already has a confirmed diagnosis and previously known to Cardiology Consultants Open access ECHOs – if heart failure confirmed this will result in direct referral to the service for assessment/ further investigations and formulation of management plan Limited service provision (no domiciliary service) but willing and happy to help where we can. To discuss any patient on an individual basis – please contact us via Dorset County Hospital 01305 255610 (24 hour voicemail) [email protected] Q. Why are they no longer with us? Answers: 1. Late diagnosis 2. GP didn’t have access to BNP or Heart Failure Services 3. Beta blockers not available in Chechnia 4. Too much cocaine/ alcohol