Download gp_hf_presentation_2007

Management of Heart Failure
Overview
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Interactive exercise
What colour are your sunglasses?
Update on pathophysiology of HF
Interactive case study
Heart failure with preserved systolic function
Discussion
Close
Which treatment do you want?
%
survival
A
B
C
time
What colour are your lenses?
Pathophysiology
How we think about the failing heart affects
our treatment strategies
Changes in mechanistic understanding:
1. Cardio-centric view
2. Cardio-renal view
3. Neuro-hormonal view
Cardiocentric view
• Reduced cardiac output is the “cause”
• Cardiac compensatory mechanisms
– Frank-Starling curve
– LV dilatation
– LV hypertrophy
• Problems
– Positive inotropes kill!
– Still some research on calcium sensitisers etc
• Benefits
– Cardiac resynchronisation
Cardiorenal view
• Reduced perfusion to the renal arterioles causes
salt and fluid retention (RAAS)
• Aim of treatment is to normalise volume status
– Focus on diuretics and fluid balance
– Stimulated development of ACEi / ARB’s /
Aldosterone antagonists
– New developments
• Direct renin inhibitors
– Know the eGFR but …
Neurohormonal view
• Heart failure is due to chronically activated
compensatory mechanisms
– Autonomic nervous system
– Renin-Angiotensin-Aldosterone system
– Role of the peripheries (muscles, arterioles)
• Stimulated treatments
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Beta blockers
ACEi/ARB/aldosterone antagonists
Natriuretic peptides
Exercise
Cardiac
output
Heart
Failure
Ventricular
contractile
dysfunction
Aldosterone
antagonists
vasodilators
Aldosterone
Angiotensin II
Sympathoadrena
l activation
peripheral
resistance
ARB
ACEi
Angiotensin I
Diuretics
Salt and
water
retention
Renin
inhibitors
NPs
Renin
Renal
perfusion
BB
Case study
• Jean
• 76 year old lady
• Long history of type 2
diabetes (diet controlled)
• Previous episode of gout
• “mild” COPD
• Resistant hypertension for
years
• Drugs
– Atenolol 50
– Verapamil 120 bd (but
only taking evening)
– Aspirin 75
Tried
– Felodipine
– Bendroflumethiazide
– Doxazosin
Presenting complaint
• Increasing abdominal swelling
• Increasing breathlessness on exertion
• Some ankle swelling
Examination
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Pulse 110 irreg irreg
BP 176/94
JVP visible 3 cm
Pitting oedema (mild)
Distended abdomen but …
Heart sounds normal
Chest clear
Discuss
• What do you think is going on?
• What tests will you request and where?
• Are you going to start any treatment now?
7 mins
What the GP did
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ECG in the practice
Open access CXR
Open access U/S abdomen
Bloods
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FBC
U&E
LFT
TFT
• Started frusemide 40 mg od
Results
• FBC
– Hb 9.7
MCV 85
• U&E
– Cr 120
eGFR 56
K 4.5
• CXR
– Clear lung fields. Enlarged cardiothoracic ratio
• U/S Abdo
– Dilated hepatic veins consistent with heart failure
• ECG
– AF rate 110
LBBB
QRS duration 150ms
Discuss
• Is the diagnosis clear?
• More tests?
• Referral
– Where?
– Choose and book?
• Treatment?
7 minutes
What the GP did
• Referred to Cardiology at BRI by letter
– 24th August 2007
• Triaged by Cardiology Consultants
– One stop clinic
– Seen 19th September 2007
One stop clinic
• Designed to see patients who are likely to need a
test and review
• 7 new patients twice a week
• Suitable for:
– Breathlessness, arrhythmias, murmurs, chest pain and
pre-op assessment
• Patients warned may take all morning!
• ECG on arrival
• Letter reviewed and sent for echo prior to being
seen
Echo
Discuss
• Heart Failure treatment
• AF treatment
• Follow up
5 minutes
What the Cardiologist did
• Make the diagnosis
– Heart failure with impaired LV systolic function
secondary to hypertension
– AF
• Recommend changes in treatment (by GP)
– Stop verapamil, atenolol and aspirin
– Start bisoprolol, ramipril and warfarin
• Letter to GP and patient
• Discharged back to GP
• Review by Heart Failure nurses for education and
monitor uptitration
Discuss
• Uptitration of drugs
– By whom?
– Monitoring of renal function
• What would trigger referral back to secondary
care?
• Anaemia
– Investigate? Causes? Treatment?
5 mins
Heart Failure with preserved
systolic function
• 40 - 60% of HF
• Elevated LV filling pressures
• Normal ejection fraction on echo
– Other supporting signs of heart failure
• Typical patient
– Elderly
– Female
– Hypertension
Question?
• What would you have done differently if an open
access echo had come back showing:
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Good LV systolic function
Mild concentric LVH
Mild mitral regurgitation
Moderate tricuspid regurgitation
Moderate pulmonary hypertension
Probable diastolic dysfunction
2 mins
“Diastolic” Heart Failure
• Poor response to haemodynamic stress
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AF
Tachycardia
 BP
Ischaemia
• Little direct trial evidence
– CHARM preserved
– SENIORS
Treatment options
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Control BP
Control heart rate (esp in AF)
Control congestion
Revascularise if driven by ischaemia
• Be careful not to reduce preload too much
Discussion
Questions
Comments