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Heart Failure Simon Woldman
Speaker key
IV
SW
Interviewer
Simon Woldman
SW My name is Simon Woldman. I'm the Clinical Lead for Heart Failure for
University College Hospital. My talk today was about the organisation Heart Failure
Services in Camden, and about how to diagnose heart failure.
IV
How are the Heart Failure Services in Camden organised, and are there any
changes?
SW Heart Failure Services in Camden, historically, have been very good, but
multiple different agencies were feeding into the heart failure patient, but without any
coordination. Now we have taken several steps to improve that by using technical
solutions like EMIS Web, which is a GP notes system, which secondary care doctors
can use, by putting in resources into the community nurses, where they now have
clinical leadership from secondary care, and by setting up a heart failure steering
group consisting of two GPs and two consultant cardiologists, who will look a the
management of heart failure in Camden in totality.
IV
What is the aim of the service?
SW The aim of the service is to try to treat as many patients with heart failure as
well as we possibly can. We have a problem in Camden that only 0.6% of the
population are diagnosed as having heart failure, but the expected prevalence is
probably closer to 1.2%. In order to deal with our problem of high admission and
readmission rates we need to make sure that we identify many more patients before
they come to hospital with heart failure, and that involves early diagnosis and accurate
diagnosis, and then appropriate treatment, which has been difficult for us to achieve in
the past.
IV
How do GPs diagnose heart failure?
SW If heart failure diagnosis is considered then, if the patient has had a previous
myocardial infarction, they should be sent direct to secondary care for a diagnosis to
be confirmed. If a patient has not had a previous myocardial infarction then a BNP
measurement should be made. If the level is very high, above 235 picomoles per litre,
then the patient should be again referred for assessment within two weeks to
secondary care. If the BNP is moderate, between 47 and 235 picomoles per litre then
the patient should be sent routinely, within six weeks, to be seen by secondary care,
for confirmation of the diagnosis.
IV
How does it usually present?
SW Heart failure usually presents with breathlessness and ankle swelling, as we
were all taught in university, but it can present as malaise, tiredness, weakness,
nausea, even, in some patients. It's particularly important to think of these symptoms
as being heart failure if the patient is known to have left ventricular systolic
dysfunction, for example, if they’ve had a previous heart attack.
IV
How can GPs improve the diagnosis rate?
SW We have a lot of work to do to improve the diagnosis rate. It's important to
consider other symptoms as potential causes of heart failure, to look back at some GP
records, to see if patients are getting drugs that might be used to treat the symptoms of
heart failure, for example, diuretics, but yet have not got a formal diagnosis of heart
failure, and indeed, in some of the screening programme we have discovered patients
that have been taking medication for a very long time, but actually don’t have a
formal diagnosis of heart failure, nor are properly treated for it.
IV
What tests are there in primary care to enable diagnosis?
SW The principle test that's available in primary care is measurement of the BNP.
BNP is a very sensitive marker of left ventricular systolic dysfunction. As the left
ventricle expands BNP is increasingly released. It's sometimes falsely low in patients
on ACE inhibitors, and one has to be aware of that, but other than that a negative BNP
almost excludes the diagnosis of heart failure.
BNP though, should not be measured in patients with a previous myocardial
infarction because the diagnosis of heart failure is so likely, and also because the
diagnosis of heart failure is so significant in these patients that they should be referred
rapidly to secondary care for assessment and diagnosis, so that treatment can be
initiated before the patient either dies or gets admitted to hospital.
IV
Are there any important differential diagnoses?
SW Yes, there are a lot of very important differential diagnoses for patients who
present with breathlessness. Principal amongst them is COPD, but one of the
commonest causes that I see of breathlessness in my clinic is either anaemia or
obesity, so many other conditions need to be considered when a patient presents with
breathlessness, not just heart failure.
IV
Are there any common pitfalls in diagnosis to try to avoid.
SW Yes, there are important pitfalls. The most common of these are anaemia, so a
misdiagnosis of anaemia, which can mimic heart failure, a misdiagnosis of valvular
heart disease, which of course mimics heart failure, and other things like obesity and
chronic obstructive pulmonary disease that also need to be thought about.
IV
Once diagnosed what should a GP do next?
SW If the GP suspects heart failure they should refer the patient to secondary care,
but the urgency will be dictated by the clinical circumstances. Patients who have had
a previous myocardial infarction, or who have a very high NT-proBNP should be
referred urgently to be seen within two weeks. Patients who have a lowish NTproBNP but above the threshold of 47 picomoles per litre should be referred routinely,
and will be seen within six weeks.
IV
What advances to improve diagnosis will there be in the next five years?
SW Over the next few years we're going to see a change in the emphasis of heart
failure diagnosis, I'm certain. Previously we have not worried too much about what
the cause of the heart failure was, but treated them all equivalently. That's going to
change. Patients with dilated cardiomyopathy often have a first degree relative with
heart failure, and they need to be screened. Patients who have ischaemic
cardiomyopathy may well get revascularisation. Patients who have myocarditis may
be suitable for biopsy and identification of the virus causing it, and so on and so forth.
It will be about the diagnosis of the cause of the heart failure, and the treatment of the
specific cause, in addition to the treatment of the heart failure.
IV
Where can GPs find out more?
SW GPs can find out more from the NICE guidance, and also from the Camden
website, which has full details of the new heart failure pathway for Camden
SW I can be contacted at UCLH. We have a new email address. Our email address
is [email protected].