Heart Failure in Primary care

Lucy McGurn Sarah Green

Learning Objectivesa) Increased awareness of the scale of the problem

b) Improved knowledge of the most appropriate general investigations

c) Confidence with drug management of heart failure

d) Increased awareness of non-pharmacological interventions and their effectiveness

e) Improved understanding of when to refer on to secondary care

Heart Failure• Occurs when output of the heart is inadequate to meet

the needs of the body

• End stage of all diseases of the heart

• Prevalence 1-1.6% (10-20% >75yrs)

• Poor prognosis can be improved by early and optimal treatment

• Increasingly important as population ages

• Causes – IHD, hypertension, valvular disease, alcohol, hyperthyroidism

Mr Jones is an 78-year-old widower who has attendedyour afternoon surgery because of increasingshortness of breath and fatigue on exertion. He says

heis struggling to play a whole round of golf.

He was last seen in his over-75 health check when itwas noted that his BP was 160/80 with a BMI of 29.8,but otherwise there were no problems identified.

He has been a lifelong smoker and his diet has been poor

since his wife died of breast cancer 4 years ago.

What do you think is wrong with Mr Jones?

Making the diagnosis - Symptoms

LVF (back pressure into pulmonary system)SOB on exertion Nocturnal cough PND

Orthopnoea Wheeze LethargyReduced exercise tolerance

RVF (back pressure into peripheral circulation)Ankle oedema Nausea and anorexiaFatigue and wasting Abdo pain due to hepatomegalyIncreased weight

CCF (failure of both ventricles)

(Remember to ask about chest pain and palpitations)

New York Heart Association Classification of Heart Failure

Class I - No limitations Ordinary physical activity does not cause undue fatigue dyspnoea or palpitation(asymptomatic left ventricular dysfunction)

Class II - Slight limitation of physical activity Such patients are comfortable at rest. Ordinary physical activity results inFatigue, palpitation, dyspnoea or angina pectoris (symptomatically‚ mild heart failure)

Class III - Marked limitation of physical activityAlthough patients are comfortable at rest, less than ordinary physical activity will lead

tosymptoms (symptomatically‚ moderate heart failure)

Class IV: Inability to carry on any physical activity without discomfortSymptoms are present even at rest. With any physical activity increased discomfort isexperienced (symptomatically‚ severe heart failure)

You examine Mr Jones – what might you find??

Making the diagnosis - Signs

Cachexia and muscle wasting Tachypnoeic +/- cyanosis Tachycardia +/- gallop rhythm Cardiomegaly and displaced apex Right ventricular heave Raised JVP Basal creps +/- effusions +/- wheeze Ankle oedema Hepatomegaly Ascites

When you examine Mr Jones you find signs of left

and right heart failure.

What further investigations do you want??

Making the diagnosis - investigations

a) Weight – good for trend

b) BP

c) ECG – IHD changes, LVH, slow AF

d) Bloods – U&E, TFT, LFT, FBC, Lipids, Gluc, natriuretic peptides

e) CXR

f) Urinalysis

g) PEFR/spirometry – if uncertain about Dx

Making the diagnosis –NICE Guidance

• New guidance 2010 replacing 2003

• Good algorithm on diagnosis of heart failure in quick reference guide

• If previous MI refer

• If no previous MI then measure natriuretic peptides

You measure Mr Jones BNP when comes back at256 pg/ml

What do you do next? – follow NICE algorithm

When would you refer to secondary care – thinkabout the patients you see in your practice withheart failure.

When to refer to specialist multidisciplinary team?

a) Initial diagnosis of heart failureb) Severe HF (class IV)c) HF not responding to treatmentd) HF due to valve diseasee) HF that can’t be managed at homef) Women thinking of pregnancy

g) Suspected HF and previous MI – urgent 2/52

Mr Jones attends hospital and has an echoshowing a reduced ejection fraction. TheCardiologist starts him on 2 medications whatmight they be?

Mr Jones attends hospital and has an echoshowing a reduced ejection fraction. TheCardiologist starts him on 2 medications whatmight they be?

Combination of an ACE-inhibitor and β-blocker

Treatment of heart failure – ACE Inhibitors

- Captopril, Enalapril, Lisinopril, Ramipril

- Start low and titrate up every 2/52

- Monitor U&E, eGRF & BP – at initiation/after increase (expect small increases)

- if suspect valve disease don’t start

- use angiotensin II receptor antagonist if SE’s (valsartan, candesartan, losartan)

Treatment of heart failure - βblockers

- Carvedilol, bisoprolol (short-acting)

- Good for HF due to LVSD

- Start low and titrate up every 2/52

- monitor HR, BP, clinical status

- can give to elderly, PVD, diabetes, interstitial pulmonary disease COPD (without

reversibility)

- don’t just stop as get rebound – ischaemia/arrythmias

You managed to get him stable on his medications withinitial frequent monitoring. He then remains well for thenext few years with 6 monthly checks.

Mr Jones returns to see you with worsening ankle oedemaand increasing SOB. He says he has had to stop playing

golfand is even having difficulty managing the hill up to thecorner shop.

What is his NYHA class now?

What drug might you add in?

Treatment of heart failure – diuretics

• Loop (furosemide) or thiazides (bendroflumethiazide)

• Use minimum effective dose to control congestive symptoms and fluid retention

• Monitor for hypokalaemia

What else could you recommend??

Lifestyle and Rehabilitation

Educate – about the disease, current/expectedsymptoms, need for Rx, prognosis

Discuss ways to make life easier – e.g. Benefits,

mobility aids, blue badge, social servicesassessment for extra help

Diet – adequate calories, low salt, lose weight ifobese, restrict alcohol

Lifestyle and Rehabilitation

Lifestyle measures – smoking cessation, regular

exercise

Restrict fluid intake – 1.5-2 litres/day

Vaccination – pneumococcal + annual influenza

Assess for depression

You are asked to do a home visit to see Mr Jones as he rang

earlier saying his breathing was a bit worse than usual thismorning.

On arrival at his house it takes Mr Jones at least 5 minutesto answer the door. He is acutely short of breath and ishaving difficulty speaking in full sentences. He mentionssome tightness in his chest.

What may have happened??

What would you check??

You are asked to do a home visit to see Mr Jones as he rangearlier saying his breathing was a bit worse than usual thismorning.

On arrival at his house it takes Mr Jones at least 5 minutesto answer the door. He is acutely short of breath and is havingdifficulty speaking in full sentences. He mentions some

tightnessin his chest.

What may have happened??

What would you check??

You confirm fast AF with gross pulmonary oedema and ring foran ambulance.

Atrial Fibrillation• Can be difficult to know if AF is the cause or an

effect of heart failure

• Digoxin used as improves ejection fraction as well as decreasing hospital admissions

• Increasing prevalence with worsening heart failure Class I – 4%

Class II -10-26%Class III – 20-29%Class IV – 50%

Mr Jones has 4 further hospitals admissions overthe next few months. He now has home care goingin twice a day.

The district nurse asks you to go and see him asshe feels he is getting worse again.

What issues should you raise?

Longterm care and palliation

Poor prognosis - progressive deterioration to death• 50% die suddenly – probably due to arrhythmias• Mild/Moderate HF 20-30% 1yr mortality• Severe HF >50% 1yr mortality

Make use of specialist heart failure nurses

Involve palliative care

Think about resuscitation status

References/Resources

• Oxford Handbook of General Practice, Simon, Everitt and Kendrick, Oxford University, 2005

• Chronic Heart Failure – Quick reference guide, NICE, Aug 2010

• E-learning module – doctors.net

• British Heart Foundation Website