Download heart failure - NHS South Worcestershire CCG

HEART FAILURE
Excellent Care
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1. Diagnosis
2. ACE-I and B blocker
3. Aldosterone antagonist
4. Exercise
5. Statin and aspirin if CVD
6. Digoxin with AF
7. Lifestyle
8. Ivabradine
9. Monitoring
Diagnosis
• 1. ECG
• 2. BNP
• 3. CXR – for possible alternative
diagnoses (together with blood tests and
spirometry)
• 4. Echo
Drug therapy
• 1. ACE-I (or ARB if not tolerated). Titrate to evidence based dose –
practically speaking this is usually the maximum dose.
• 2. Bisoprolol, carvedilol (or nebivolol for those over 70). A 20,000
patient (23 trial) meta analysis found 18% reduction in risk of death
for every 5 bpm reduction in resting HR. No correlation between
dose and death, ie higher doses are not better at reducing deaths
than lower doses. The study strongly suggests reducing pulse is
more important than dose. In sinus rhythm aim for 60 bpm. If resting
pulse falls to < 50, halve the B blocker dose.
• In HF + AF keep HR > 70. Aim for 73 – 82 bpm.
bradyarhythmias at night.
?Prevents
Drug therapy (cont)
• 3. Aldosterone antagonist. Spironolactone or eplerenone.
Used to be recommended in NYHA III – IV if EF =/<35%.
New evidence – use in NYHA II – IV (with EF =/<35%).
• 4. Aspirin and statin if CVD.
• 5. With AF & HF, if pulse not reduced to 73 – 82 bpm by
B blocker, then add digoxin.
• 6. Ivabradine – specialist use only – not if any risk of AF.
Exercise and Lifestyle
• NICE: “Offer a supervised group exercise- based
rehabilitation programme designed for patients
with Heart Failure.
Ensure the patient is stable and does not have a
condition or device that would preclude the
programme.
• …psychological and educational component.”
• Smoking, alcohol, sexual activity, imms.
Monitoring
• 1. Functional capacity, fluid status, rhythm, cognitive and nutritional
status
• 2. Drugs
• 3. U&Es and eGFR.
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• When starting aldosterone antagonist check U&Es 7 – 14 days later,
with each dose change, and eventually at the very least every 6
months.
• Amiodarone needs 6 monthly TFTs & LFTs.
• Initially monitor patient’s clinical condition at short intervals (days to
2 wk) if condition / drugs change. Otherwise monitor at least 6
monthly.
4 Questions
• 1. Diagnosis.
• Primary Care – Can take several wks from
decision for echo to results. Echos on ICE?
Secondary Care – Should all patients with heart
failure diagnosis have an echo while in patient.
Need to know if heart failure symptoms or actual
LVSD.
If not possible, then ?hospital BNP screen
followed by echo if positive.
4 Questions
• 2. Titrating B blockers
• Aim for pulse of 60 bpm, not dose of B
blocker.
• 72 – 83 bpm in AF.
4 Questions
• 3. Blood monitoring
• U&Es after initiation and after every dose
change of ACE-I / ARB / spironolactone.
BNF: Thereafter minimum 6 monthly U&Es
Also 6 monthly TFTs and LFTs if on amiodarone
4 Questions
• 4. Frequency of patient clinical
monitoring
• 6 monthly monitoring when stable.(NICE)
• ?Alternating between practice nurse and
GP.