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Heart Failure:
From Failure to Success
Dr. Alison Seed
Consultant Cardiologist
Failures?
• In diagnosis
• In routine management
• In advanced management
₤ To address the personal AND financial burden
Diagnosis...........
Prevalence
>45yrs
National
(expected)
National
Blackpool PCT
(recorded)
2.3%
1.8%
(0.19-5)
1.Pushing the boundaries: Improving services for people with heart failure. HCC(CHAI ) 2007
2. State of healthcare: Improvements and challenges for services in England and Wales. HCC (CHAI) 2007
3. Blackpool GP HF register data: Brian Harrop, Blackpool PCT
Routine management..........
MORTALITY BENEFIT OF BETA-BLOCKERS AND
ACE-INHIBITORS IN CHF TRIALS
16
S
SOLVD (1991)
CIBIS II
MERIT-HF
(1999)
14
% death at 1 year
12
10
8
6
4
2
0
diuretic
digoxin
diuretic
digoxin
ACE-I
diuretic
digoxin
ACE-I
diuretic
digoxin
ACE-I
beta-blocker
Advanced management........
Implant rate / million population / year
Lancs.
UK
UK
South
target average Cumbria
2006
USA
average
EU
average
ICD
610
160
100
46
28
Bi V
PPM
275
75
140
56
58
Personal and financial burden...
 Poor prognosis
– 10-50% mortality per year
 Poor quality of life
– Poor exercise tolerance
– >30% depressive illness
 Frequent hospital admission
– 5% of acute medical admissions
– 40% death /readmission in one year
 Long length of stay
– > 8 days
– 2% of in patient bed days
2% total
annual NHS
expenditure
Cost
Hospital admission
length of stay
Healthcare Commission 2007
• HF diagnostic services poor
− Diagnosis difficult because symptoms non specific
and physical signs not obvious
− Early diagnosis leads to appropriate life saving and
symptom reducing treatment
• Limited access to heart failure specialists
− Need to target advanced treatments at high
risk patients
₤ Rates of hospitalisation remain high
Healthcare Commission. Pushing the boundaries: improving services for people
with heart failure. London Healthcare Commission, 2007
Are we offering..........
Advanced Care
or
Palliative Care
........... to our Patients with
Heart Failure?
Currently (2009)….
 Inequitable care
 Only for the symptomatic patient seeking
help
 No more than Crisis management for the
majority
Palliative Care that could be
better !!
National drivers
 Quality Outcomes Framework
 ‘Advancing Quality’ (NW SHA)
 National HF database
 Darzi report
– Equitable, efficient, patient centred care
– Health improvement (outcomes and quality)
– Adherence to best practice
(NICE, NSF)
 Financial climate
– Avoid hospital admission
– Manage chronic disease in primary care
Our aim….
‘Best care’ whenever and wherever
patients require it ............
 Not currently seeking attention
– Not yet diagnosed
– With confirmed diagnosis
 New presentation
− In Primary Care with symptoms
 Hospital admission(s)
− With severe heart failure
Our aim....
To demonstrate that optimal care is cost
saving...................
Failures?
• Diagnosis
• Routine management
• Advanced management
Definition: The first problem
European society of Cardiology:
‘typically breathlessness or fatigue, either at
rest or during exercise, or ankle swelling; and
objective evidence of cardiac dysfunction at
rest (usually on echocardiography)’
BLACKPOOL FYLDE AND WYRE HOSPITALS NHS FOUNDATION TRUST
LANCASHIRE CARDIAC CENTRE
Improving Diagnosis and Outcomes in
Chronic Heart Failure
PROPOSAL 1
Patients presenting with breathlessness and patients on the listed chronic disease
registers, attending for routine review, should be asked to complete an NYHA
questionnaire while waiting to see the practice Nurse / doctor. Those whose
answers suggest that they are in NYHA II or above should have a BNP test and
be considered for referral to the one stop Heart Failure Diagnostic Clinic
(HFDC) or open access echocardiography service.
Class
New
York
Heart
Association
NYHA > II
Further investigation
required
Symptom
1
No limitation
Ordinary physical
activity does not cause
tiredness,
breathlessness, chest
discomfort or palpitation
(an unexpected
awareness of your
heartbeat).
2
Slight limitation
You are comfortable at
rest but physical
activity causes some
tiredness,
breathlessness, chest
discomfort or palpitation
(an unexpected
awareness of your
heartbeat).
3
Marked limitation You are comfortable at
4
Inability to carry
out any physical
activity without
discomfort
rest, but everyday
activities cause
marked tiredness,
breathlessness, chest
discomfort or palpitation
(an unexpected
awareness of your
heartbeat).
You have significant
breathlessness or chest
discomfort at rest. Any
physical activity causes
your symptoms to get
worse.
BNP
 Brain-type Natriuretic Peptide (BNP) is a
hormone, secreted in the ventricular
myocardium during periods of increased Atrial
and ventricular wall tension
 It is the most powerful marker of cardiovascular
morbidity and mortality including sudden death
 An elevated BNP indicates that the heart or
kidneys are not working well but does not tell
exactly why
NICE Guidance 2010
Symptoms of HF
Previous MI?
NO
YES
Check BNP
HIGH (>100)
‘VERY HIGH’ (>400)
poor prognosis
Refer for urgent
Echo
and
Specialist assessment
(within 2 weeks)
Refer for
Echo and
specialist
assessment
routinely
REFERRAL FORM AND CHECKLIST
Please fax this referral and blood results if required to :
Heart Failure Team Fax no: 01253 657845 or referral form initially to [email protected]
Heart
Failure
Diagnostic
Clinic
HEART FAILURE DIAGNOSTIC CLINIC IS A ONE STOP DIAGNOSTIC CLINIC FOR ANY PATIENT
WITH SYMPTOMS/SIGNS SUGGESTIVE OF HEART FAILURE BUT NO PREVIOUS DIAGNOSIS

In addition to echocardiogram and in accordance with NICE guidelines the following will be considered :
The aetiology of heart failure and treatment if required of this condition
The need for additional diagnostic tests eg. stress echo, transoesophageal echo, angiogram
Pharmacological and non pharmacological therapy
The role of device therapy

Diagnosis and management plan will be discussed with a view to increasing patient engagement / compliance

A ‘patient held’ record of diagnosis / management will be produced and recorded on a National HF database

This single visit to hospital will better support the subsequent management of the majority of pts in Primary Care

The management and surveillance of the most complex/at risk patients will be undertaken by the hospital HF
team in consultation with their General Practitioner and the Community HF team
Patient details
Referring GP
Name :
Name :
Address :
Address:
Postcode :
Tel. no :
Tel.no :
Fax. no:
DOB :
One stop
Within 2
weeks
NHS no :
Hospital no :
Referral date:
PCT area :
If the patient does not meet one of the following criteria or has had echocardiogram in the last twelve months –
please do not refer to One Stop HFDC
Refer to cardiology via usual channels or to the HF team directly by letter if previously known to them
Yes
Details
The patient has symptoms suggestive of HF and
history of myocardial infarction in the past
The patient has symptoms suggestive of HF and
an elevated BNP
or
BNP is unavailable to your practice
BNP result :
Hospital where assay performed:
we are working with Cardiac Network to improve access
APPOINTMENT AT HFDC WILL BE OFFERED WITHIN 2 WEEKS OF CHOOSE AND BOOK REFERRAL,
RECEIPT OF COMPLETED REFERRAL FORM and if required (see above) BNP result
All patients should have had blood taken for U&E and FBC – result need not delay referral
REFERRAL TO HFDC WILL BE ACCEPTED WITHOUT BLOODS FOR THOSE WITH ALARM FEATURES
THIS IS OFFERED ONLY AS AN ALTERNATIVE TO HOSPITAL ADMISSION IF FELT APPROPRIATE
(please tick)
Heart Failure Diagnostic Clinic
Comprehensive specialist assessment
 History/ examination
 Echocardiogram
 Consideration of need for further investigation
– Angiogram, TOE, stress test
 Management plan
-
Lifestyle
Pharmacological
Non pharmacological
Device therapy
 Patient education / engagement
• HF referral poster
• AQ data
Failures?
• Diagnosis
• Routine management
• Advanced management
Failures?
• Diagnosis
• Routine management
• Advanced management
Biventricular Pacemakers
Right Atrial
Lead
Right Ventricular
Lead
ECG
• P wave
• QRS duration
37
38
Biventricular Pacemakers
Right Atrial
Lead
Left Ventricular
Lead
Right Ventricular
Lead
Biventricular Pacemakers
Biventricular Pacemakers
36% reduction
in All Cause Death / CVS death /Hospitalisation
CARE – HF: Cleland et al, NEJM, 2005
• Referral for CRT from North Lancs/
Blackpool
Transplant vs. medical Rx
Butler et al. J Am Coll Cardiol, 2004
Cardiopulmonary exercise
testing
Survival
following
cardiac
transplant
• 1 year: 85%
• 5 years: 73%
• 10 years: 58%
www.uktransplant.org.uk
Mechanical support:
Ventricular
assist devices
Outflow: Ao
Inflow: LV/LA
• Bridge to transplant
• Bridge to recovery
• Destination therapy
Who should receive a VAD as bridge
to transplant?
Heart Failure Service - Blackpool
Timely and accurate diagnosis
 One stop diagnostic clinic
Appropriate/safe/rapid referral pathways
 Identify high risk patients
 BNP
Efficient and effective clinical care
 Treatment optimisation (NICE)
 Non pharmacological intervention (CRT / ICD, LVAD, Tx)
 Communication , Communication, Communication
New
presentation
to GP
Hospital
Discharge
HIGH RISK
GROUP
In order to reduce
risk of readmission
all inpatients will be
seen during
admission or early
post discharge by
specialist team
Known
diagnosis in
Primary Care
Previous MI?
•
Community Heart
Failure Service
No
• Uptitration to maximal
tolerated medical therapy
BNP ?
Yes
>
threshold
Heart Failure
One stop
Diagnostic clinic
• See referral form
• Seen within 2 weeks
• Aim discharge with
management plan for
majority
• HF helpline
•
•
• Ongoing surveillance /
management of those at
high risk of readmission
Acute Trust HF nurse also
available for advice
/ to facilitate seamless care
HF helpline:
01253 303269
*
Specialist Consultant led clinic to see all
high risk patients ie. :
• LBBB on ECG
• New AF
• Angina
• Any ongoing symptoms despite
maximal tolerated medical therapy
• Uptitration to
maximal tolerated
medical therapy
• Ongoing surveillance
All patients should have
routine 6 monthly review of:
• Symptoms
• Medication
• ECG: LBBB, AF, HR
• UE, FBC
Specialist
Consultant led
HF clinic
HIGH RISK
GROUP
Referral by:
• Direct letter
• HF helpline
01253 657865
• Discharge to GP of stable
patients
GP follow up
Advice required
High risk
(see markers below)
Unable to achieve
target dose of
medication
Key
___
*
Attached
Patient numbers to be continually
audited and reported by Acute Trust
Final achievement of target medical
therapy doses to be periodically audited
and reported by Acute Trust
HFDC referral form
Discharge report (example)
Uptitration advice form
Thank you
Any questions?