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HF diagnosis: audit of NTproBNP uptake and outcomes
across Sheffield
An update on diagnosis and management of HF
Dr Abdallah Al-Mohammad, MD, FRCP(Edin), FRCP(Lond), FESC
Consultant Cardiologist,
Sheffield Teaching Hospitals NHS Foundation Trust
PLI 18 11 2015
Sheffield
I acknowledge Data on Trends of NTproBNP Testing in Sheffield from Mr John
Soady
The unique Sheffield 1
• In the UK, the place of care for HF patients is:
47.6% in cardiology wards
41.3% in general medicine
10.8% on “other” wards
• In Sheffield, the place of care for HF patients is:
18-30% in the cardiology wards
The remainder are in General Medical wards and
others
The unique Sheffield 2
• The overall in-patient mortality in the UK is 11.1%.
• The hospital mortality of HF patients is related to place of
care:
–
–
–
–
Cardiology ward (7.8%)
General medical (13.2%)
Other ward (17.4%)
After adjusting for (age>75 yrs, NYHA Class III/IV, previous MI), not
being treated in cardiology was still associated with a worse outcome
HR=1.66 (1.52-1.81), p<0.001
• In Sheffield, although the majority of patients are in Medicine,
the mortality overall is closer to those in cardiology wards
elsewhere (<10%). The difference is HF MDT
CG108-NICE 2010
• Patients WITH NEW SYMPTOMS of HF should
have NTproBNP measurements and referred
to the Diagnostic clinic if NTproBNP>400 ng/l
• These patients should have an
echocardiogram and a specialist opinion
The frequency of NP testing in
Sheffield
• Since 2012, and every month there has been a
6.2% increase in the number of tests.
• Interestingly the rise was mainly at the
expense of rising negative tests (<400)
• Within the positive tests, the rise has been
mainly in those with NTproBNP 400-2000
• Not all those with a positive tests are being
referred to Cardiology
The HF Diagnosis and Management Clinic - Workload
Patients
1000
800
600
400
200
0
Year 1
Year 2
Year 3
Year 4
(projected)
The outcomes of HF diagnostic clinic
•
•
•
•
•
•
HFPEF 33%
HF-LVSD (HFREF) 31%
No HF 24%
Pulmonary hypertension 5%
Valve problems leading to HF 3%
Other types of HF 3% (e.g RV systolic
impairment)
Update on the diagnosis and
management of HF
Dr Abdallah Al-Mohammad, MD, FRCP(Edin), FRCP(Lond), FESC
Consultant Cardiologist,
Sheffield Teaching Hospitals NHS Foundation Trust
PLI 18 11 2015
Sheffield
Diagnosis
• The patient has symptoms of HF probably with
signs if one looked for them
• The patient with no prior therapy will have a
raised NTproBNP
• The diagnosis can not be made without
imaging the heart
HF-LVSD: HFREF
• The type of HF that affects less than 50% of
the HF patients in the community
• There is evidence based therapy
• Unless the patient has a contra-indication, all
patients with HFREF should be treated with
ACEi and a Beta blocker proven to be effective
in HF (Bisoprolol, Carvedilol, Metoprolol,
Nebivolol)
HFREF 2
• Once on the maximum tolerated doses of ACEi
and a Beta blocker effective in HF, the patients
who remain symptomatic should be
commenced on an aldosterone antagonist
(spironolactone or eplerenone)
• The combination of ACEi and AA, is usually
safe provided close monitoring of the renal
function is adhered to
HFREF 3
• Only when the side effects of ACEi are
intolerable should you switch to an ARB.
• If the cough did not disappear, please ask
yourself two questions: a. Was ACEi
responsible here? B. Should I continue to
deprive the patient from ACEi?
HFREF 4
• The black patient with SBP>125 who is already on
optimal therapy with ACEi/BB/AA should be
considered for Hydralazine and Nitrates
• If the heart rate remained >75 bpm, the patient is
in sinus rhythm and no further uptitration of BB is
possible, then consider adding ivabradine 2.5 mg
bd, and uptitrate to no more than 7.5 mg bd
(Keep HR>60bpm)
• Digoxin
Monitor
• Frequent U+E when uptitrating
• U+E at 1,4,8,12 weeks and then every 3
months; if on AA and ACEi/ARB
• 6 monthly:
Cognition/Psychology/U+E/ECG/General
status
• The ECG is to look for ? AF, and the width of
QRS >130 m sec especially if LBBB: ?CRT
HFPEF
• Treat the co-morbidities especially
hypertension. Consider treatment of
ischaemia and better diabetes control
• Diuretics for fluid overload
• Spironolactone 12.5 mg may reduce HF
hospitalisation
• In these patients there is no indication to add
ACEi/BB routinely unless for another reason
HF due to significant valve disease
• An indication for cardiology interventions,
usually surgical and increasingly TAVI for
elderly patients with severe AS
HF due to pulmonary hypertension
• Control of fluid overload with diuretics with or
without spironolactone
• ?Anticoagulate
• Referral of the very few to the Regional
Pulmonary Hypertension unit
LCZ696
• LCZ696 is a combined Valsartan and Neprilysin
inhibitor that was proven in HFREF to be
superior to ACEi
• Currently being assessed in a TA by NICE
• Implications could be huge and once licensed
we need to carefully consider what needs to
be done
ICD
• Treat ventricular arrhythmia in patients with
LVEF<35%
• Primary prevention of arrhythmia in patients
with LVEF<35%
CRT-P/D
• When the patient with HFREF and LVEF<35% is
optimally treated as above, remains
symptomatic with an ECG showing LBBB and
QRS duration of >150 msec; or if QRS 130-150
with other supportive evidence of dyssynchrony
• CRT
• CRT-D
A Al-Mohammad
THANK YOU