Heart Failure 2014

Dr Maurice PyeDr Maurice PyeConsultant CardiologistConsultant CardiologistYork District HospitalYork District Hospital

Heart Failure 2014

Introduction – numbers – prevalence Introduction – numbers – prevalence prognosisprognosis

NICE Guidelines – 2010 including recent NICE Guidelines – 2010 including recent 2014 guidance on complex devices2014 guidance on complex devices

Discuss DIAGNOSISDiscuss DIAGNOSIS Go over management Go over management Role of Secondary CareRole of Secondary Care

Heart Failure: The Problem 1

Prevalence 3-20/1000 of the populationPrevalence 3-20/1000 of the population

(80/1000 in 75+)(80/1000 in 75+) Incidence 1/1000 population per yearIncidence 1/1000 population per year

(10/1000 per year 85+) Median 76 years(10/1000 per year 85+) Median 76 years Average GP will have 30 pts with HF and Average GP will have 30 pts with HF and

suspect new diagnosis in 10/yrsuspect new diagnosis in 10/yr

Heart Failure: The Problem 2 5% of all hospital acute admissions (50% 5% of all hospital acute admissions (50%

readmitted within 3/12) and 2% of all hospital readmitted within 3/12) and 2% of all hospital bed IP daysbed IP days

Expected to rise 50% over next 20 years due to Expected to rise 50% over next 20 years due to aging popaging pop

2-3 visits to the GP per year2-3 visits to the GP per year 1/3 have prolonged/severe depression1/3 have prolonged/severe depression Annual mortality 30-40% in 1 st year then ~ Annual mortality 30-40% in 1 st year then ~

10% yr10% yr 5yr survival in GP registries = 58% compared 5yr survival in GP registries = 58% compared

to 93% for age/sex matched populationto 93% for age/sex matched population

Heart Failure: Aetiology

What are the causes of heart failure ?What are the causes of heart failure ?

Heart Failure: Aetiology

Ischaemic heart diseaseIschaemic heart disease Hypertension (LVH Hypertension (LVH risk 15x) risk 15x) Cardiomyopathy: Alcohol, genetic, chemotherapy Cardiomyopathy: Alcohol, genetic, chemotherapy

– anthracyclines and herceptin – anthracyclines and herceptin Valvular heart diseaseValvular heart disease Arrhythmias – tachycardiomyopathy – particularly Arrhythmias – tachycardiomyopathy – particularly

prolonged silent AFibprolonged silent AFib Pericardial disease – mimics --- Normal echo, Pericardial disease – mimics --- Normal echo,

signs of right heart failure – but no intrinsic lung signs of right heart failure – but no intrinsic lung disease and normal CXRdisease and normal CXR

Diagnosis

How do you diagnose heart failure?How do you diagnose heart failure?

Diagnosis

Diagnosis is difficultDiagnosis is difficult

Symptoms, signs and investigationsSymptoms, signs and investigations

Symptoms in the diagnosis of heart failure

Symptom Sensitivity % Specificity %

Dyspnoea 66 52

Orthopnoea 21 81

PND 33 76

Oedema 23 80

Signs in the diagnosis of heart failure

Clinical findings Sensitivity Specificity

Raised JVP 17 98

Crackles 29 77

Gallop 24 99

Oedema 20 80

Investigations in the diagnosis of HF: ECG

Ability of a normal ECG to exclude LV systolic dysfunction

Sensitivity 94%Specificity 61%PPV 35%NPV 98%(However one report: 27% poor LV had N ECG)

CXR in the diagnosis of heart failure:

Cardiothoracic ratio > 50% is specific, not sensitiveUseful to exclude other causes of SOB

ECHO in the diagnosis of heart failure:

‘Best test’ for assessment LV systolic dysfunctionOf those on HF treatment only 25% have significant LV

Only 25% referred from 1o care have LV systolic dysfunctionOnly 8% ? New heart failure had LV systolic dysfunction?Diastolic dysfunction and heart failure

BNP and the diagnosis of heart failure

BNP as a screening tool for HF in 1o care

Sensitivity 76 / 97%

Specificity 84 / 87%

PPV 70 / 16%

NPV 98 / 98%

BNP /NT proBNP levels

+ with age or female+ with age or female - with obesity- with obesity + in CKD+ in CKD + in raised pulmonary artery pressure COPD, PE, + in raised pulmonary artery pressure COPD, PE,

cor pulmonalecor pulmonale + in AF+ in AF + in valvular heart disease – MR , AS, MS+ in valvular heart disease – MR , AS, MS + in sepsis+ in sepsis + in pericardial disease+ in pericardial disease

BNP in LVF some caveats

Atrial fibrillation associated with higher Atrial fibrillation associated with higher BNP values so higher cut off = 200pg/ml BNP values so higher cut off = 200pg/ml increased specificity from 40 to 73% with increased specificity from 40 to 73% with redn in sensitivity from 95 to 85%redn in sensitivity from 95 to 85%

Adding BNP to clinical judgement in ER Adding BNP to clinical judgement in ER increased diagnostic accuracy from 70 to increased diagnostic accuracy from 70 to 80%80%

BNP correctly picked up more than 90% of BNP correctly picked up more than 90% of patients thought to have low clinical patients thought to have low clinical probability of LVFprobability of LVF

BNP caveats

Most dyspnoeic patients with HF have Most dyspnoeic patients with HF have values above 400 while values below 100 values above 400 while values below 100 have a very high negative predictive value have a very high negative predictive value for HF as a cause of dyspnea for HF as a cause of dyspnea

In the range between 100 and 400 plasma In the range between 100 and 400 plasma BNP concentrations can have lowe BNP concentrations can have lowe sensitivity or specificity for detecting or sensitivity or specificity for detecting or excluding HF excluding HF

NICE 2010 HFDiagnosis Key Implementations 1 Refer patients with suspected heart failure and Refer patients with suspected heart failure and

previous myocardial infarction (MI) urgently, to previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks. and specialist assessment within 2 weeks. [new [new 2010] 2010]

A BNP level above 400 pg/ml (116 pmol/litre) or A BNP level above 400 pg/ml (116 pmol/litre) or an NTproBNP level above 2000 pg/ml (236 an NTproBNP level above 2000 pg/ml (236 pmol/litre) urgently, to have transthoracic Doppler pmol/litre) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment 2D echocardiography and specialist assessment within 2 weeks. within 2 weeks. [new 2010][new 2010]

NICE 2010 HFDiagnosis Key Implementations 2 Refer patients with suspected heart failure Refer patients with suspected heart failure

and a BNP level between 100 and and a BNP level between 100 and 400 pg/ml (29–116 pmol/litre) or an 400 pg/ml (29–116 pmol/litre) or an NTproBNP level between 400 and NTproBNP level between 400 and 2000 pg/ml (47–236 pmol/litre) to have 2000 pg/ml (47–236 pmol/litre) to have transthoracic Doppler 2D echocardiography transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks. and specialist assessment within 6 weeks. [new 2010][new 2010]

NICE 2010 HFDiagnosis Key Implementations 3 a serum BNP level less than 100 pg/ml a serum BNP level less than 100 pg/ml

(29 pmol/litre) or an NTproBNP level less than (29 pmol/litre) or an NTproBNP level less than 400 pg/ml (47 pmol/litre) in an untreated patient 400 pg/ml (47 pmol/litre) in an untreated patient makes a diagnosis of heart failure unlikelymakes a diagnosis of heart failure unlikely

the level of serum natriuretic peptide does not the level of serum natriuretic peptide does not differentiate between heart failure due to left differentiate between heart failure due to left ventricular systolic dysfunction and heart failure ventricular systolic dysfunction and heart failure with preserved left ventricular ejection fraction. with preserved left ventricular ejection fraction. [new 2010][new 2010]

Caveats in role of ECHO -NICE 1.1.1.7 Perform transthoracic Doppler 2D 1.1.1.7 Perform transthoracic Doppler 2D

echocardiography to exclude important valve echocardiography to exclude important valve disease, assess the systolic (and diastolic) disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect function of the (left) ventricle, and detect intracardiac shunts. [2003]intracardiac shunts. [2003]

1.1.1.8 Transthoracic Doppler 2D 1.1.1.8 Transthoracic Doppler 2D echocardiography should be performed on echocardiography should be performed on high-resolution equipment, by experienced high-resolution equipment, by experienced operators trained to the relevant professional operators trained to the relevant professional standards. Need and demand for these studies standards. Need and demand for these studies should not compromise quality. [2003] should not compromise quality. [2003]

1.1.1.9 Ensure that those reporting 1.1.1.9 Ensure that those reporting echocardiography are experienced in doing so. echocardiography are experienced in doing so. [2003][2003]

Treatment of heart failure

General measures

Drug therapy

All major trials Rx LV systolic dysfunction

General measures for heart failure

Other than drugs what do you advise/consider for Other than drugs what do you advise/consider for your HF patients ? your HF patients ?

General measures for heart failure Risk factor managementRisk factor management

Smoking, obesity, lipids, HT, DM, Smoking, obesity, lipids, HT, DM, AlcoholAlcohol

Salt reduction(Salt reduction( 3g/day) ?? 3g/day) ?? AvoidAvoid

Calcium antagonists, NSAIDs, Anti-arrhythmicsCalcium antagonists, NSAIDs, Anti-arrhythmics OtherOther

Flu vacc, Pneumococcal vacc, Flu vacc, Pneumococcal vacc, OPD/HOME F/UOPD/HOME F/U Exercise programmeExercise programme Selected patientsSelected patients

Control AF, anticoagulation, revascularizationControl AF, anticoagulation, revascularization

Drug treatment for heart failure

Which agents prolong life?Which agents prolong life?

Which agents do you use?Which agents do you use?

Drug treatment for heart failure Diuretics Diuretics ACE inhibitorsACE inhibitors Beta blockersBeta blockers SpironolactoneSpironolactone Angiotensin II receptor blockers (ARBs) (sartans)Angiotensin II receptor blockers (ARBs) (sartans) Digoxin AF +- sinus rhythm Digoxin AF +- sinus rhythm Hydralazine and nitrates (if ACE or sartans not Hydralazine and nitrates (if ACE or sartans not

tolerated)tolerated) WarfarinWarfarin NEW PARADIGM TRIAL – ACE- neprolysin- NEW PARADIGM TRIAL – ACE- neprolysin-

NICE 2010 Heart Failure Key Implementation 1.2.2.2 Offer both angiotensin-converting 1.2.2.2 Offer both angiotensin-converting

enzyme (ACE) inhibitors and beta-blockers enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with licensed for heart failure to all patients with heart failure due to left ventricular systolic heart failure due to left ventricular systolic dysfunction. Use clinical judgement when dysfunction. Use clinical judgement when deciding which drug to start first. deciding which drug to start first. [new [new 2010]2010]

ACE I/ARB: How to do it WHOWHO

All patients with HF All patients with HF Care: KCare: K++ > 5.5 or Cr >200 or Ur >12 or Na > 5.5 or Cr >200 or Ur >12 or Na 130 or SBP < 100 or 130 or SBP < 100 or

> frusemide 80 mg od> frusemide 80 mg od WHENWHEN

Once HF confirmed (Ideally echo Once HF confirmed (Ideally echo LV function)LV function) HOWHOW

Stop KStop K++ supp and NSAID and warn re hypotension supp and NSAID and warn re hypotension U&E’s/KU&E’s/K+ + week 1 and 4 and ? 6 monthly afterweek 1 and 4 and ? 6 monthly after Low doseLow dosemid 1/52. Target dose 1/12mid 1/52. Target dose 1/12 Refer if adverse effects as aboveRefer if adverse effects as above

NICE 2010 ACE inhibitors

ACE inhibitors (first-line treatment)ACE inhibitors (first-line treatment) 1.2.2.5 Start ACE inhibitor therapy at a low dose 1.2.2.5 Start ACE inhibitor therapy at a low dose

and titrate upwards at short intervals (for example, and titrate upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target every 2 weeks) until the optimal tolerated or target dose is achieved. dose is achieved. [2010][2010]

1.2.2.6 Measure serum urea, creatinine, 1.2.2.6 Measure serum urea, creatinine, electrolytes and eGFR at initiation of an ACE electrolytes and eGFR at initiation of an ACE inhibitor and after each dose incrementinhibitor and after each dose increment[2010][2010]

Beta-blockers: How to do it WHO:WHO:

For all with mild/moderate HF (NYHA II/III)For all with mild/moderate HF (NYHA II/III) HR>60 SBP>100HR>60 SBP>100 Clinically stable >4/52, no AMI/UA >3/12Clinically stable >4/52, no AMI/UA >3/12

WHENWHEN Once EuvolaemicOnce Euvolaemic

HOWHOW Bisoprolol 1.25 (1/52)Bisoprolol 1.25 (1/52) 2.5(1/52) 2.5(1/52)3.75(1/52) 3.75(1/52)

5 (4/52) 5 (4/52) 7.5 (4/52) 7.5 (4/52) 10 mg10 mg

NICE guidance Beta blockers

Offer beta-blockers licensed for heart failure to all Offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular patients with heart failure due to left ventricular systolic dysfunction, including:systolic dysfunction, including:

older adults older adults andand patients with:patients with:

peripheral vascular diseaseperipheral vascular disease erectile dysfunctionerectile dysfunction diabetes mellitusdiabetes mellitus interstitial pulmonary disease andinterstitial pulmonary disease and chronic obstructive pulmonary disease (COPD) chronic obstructive pulmonary disease (COPD)

without reversibility. [new 2010]without reversibility. [new 2010]

NICE guidance Beta blockers

1.2.2.8 Introduce beta-blockers in a 'start low, go 1.2.2.8 Introduce beta-blockers in a 'start low, go slow' manner, and assess heart rate, blood pressure, slow' manner, and assess heart rate, blood pressure, and clinical status after each titration. and clinical status after each titration. [2010][2010]

1.2.2.9 Switch stable patients who are already taking 1.2.2.9 Switch stable patients who are already taking a beta-blocker for a comorbidity (for example, a beta-blocker for a comorbidity (for example, angina or hypertension), and who develop heart angina or hypertension), and who develop heart failure due to left ventricular systolic dysfunction, to failure due to left ventricular systolic dysfunction, to a beta-blocker licensed for heart failure. a beta-blocker licensed for heart failure. [new 2010][new 2010]

Spironolactone: How to do it

WHOWHO All patients with moderate/severe HF All patients with moderate/severe HF Care KCare K++ > 5.0 or Cr >221 > 5.0 or Cr >221

WHENWHEN Once stabilized on ACE IOnce stabilized on ACE I

HOWHOW Dose 25 mg/dayDose 25 mg/day U&E’s/KU&E’s/K+ + week 1 and 4 and ? 3-6 monthly afterweek 1 and 4 and ? 3-6 monthly after

Aldosterone Antagonist NICE 2010

Aldosterone antagonists (second-line treatment)Aldosterone antagonists (second-line treatment) See also recommendations 1.2.2.3 and 1.2.2.4.See also recommendations 1.2.2.3 and 1.2.2.4. 1.2.2.10 In patients with heart failure due to left 1.2.2.10 In patients with heart failure due to left

ventricular systolic dysfunction who are taking ventricular systolic dysfunction who are taking aldosterone antagonists, closely monitor aldosterone antagonists, closely monitor potassium and creatinine levels, and eGFR. Seek potassium and creatinine levels, and eGFR. Seek specialist advice if the patient develops specialist advice if the patient develops hyperkalaemia or renal function deteriorates[hyperkalaemia or renal function deteriorates[2222]. ]. [new 2010][new 2010]

Lives saved with Rx

TRIALTRIAL Lives saved/1000/yearLives saved/1000/year

HOPEHOPE <1<1

SOLVD-PSOLVD-P 77

SOLVD-RSOLVD-R 1717

MERITMERIT 3838

CIBISCIBIS 4242

RALESRALES 5252

COPERNICUSCOPERNICUS 7070

Heart failure - whats on the horizon

New Ace inhibitor Neprolysin New Ace inhibitor Neprolysin inhibitor PARADIGM HF inhibitor PARADIGM HF study ECS 2014 study ECS 2014

Previous Guidance TA95 2006For Complex devices CRT or ICD ICD if;ICD if;

LVEF <35%, NSVT on Holter AND positive V-STIMLVEF <35%, NSVT on Holter AND positive V-STIM OROR

LVEF <30%LVEF <30% QRS >120msQRS >120ms

No worse than NYHA 3No worse than NYHA 3 High risk conditionHigh risk condition Secondary preventionSecondary prevention

Previous Guidance TA120 2007

CRT ifCRT if NYHA 3 or 4NYHA 3 or 4 Sinus RhythmSinus Rhythm Optimal medical RxOptimal medical Rx QRS > 150ms OR 120-149ms with echo QRS > 150ms OR 120-149ms with echo

dyssynchronydyssynchrony EF <35%EF <35%

More Data since 2007

ICDICD DEBUT 2003DEBUT 2003 DINAMIT 2004DINAMIT 2004 SCD-HeFT 2005SCD-HeFT 2005 IRIS 2009IRIS 2009

No benefit early post MINo benefit early post MI Benefit in non - ischaemic cardiomyopathyBenefit in non - ischaemic cardiomyopathy

More Data

CRTCRT RETHINQ 2007RETHINQ 2007 PROSPECT 2008PROSPECT 2008 REVERSE 2008REVERSE 2008 MADIT CRT 2009MADIT CRT 2009 RAFT 2010RAFT 2010 ECHO-CRT 2013ECHO-CRT 2013

Lack of benefit (harm) in normal QRS, benefit in Lack of benefit (harm) in normal QRS, benefit in NYHA 1 and 2NYHA 1 and 2

Echo dyssynchrony assessment unhelpfulEcho dyssynchrony assessment unhelpful

NICE GUIDANCE 2014ANY HEART FAILURE, LVEF ≤ 35%

QRS QRS durationduration

NYHA 1NYHA 1 NYHA2NYHA2 NYHA3NYHA3 NYHA4NYHA4

<120ms<120ms ICD IF THERE IS A HIGH RISK OF SCDICD IF THERE IS A HIGH RISK OF SCD NO DEVICENO DEVICE

120-149ms, no 120-149ms, no LBBBLBBB

ICDICD ICDICD ICDICD CRT-PCRT-P

120-149ms 120-149ms with LBBBwith LBBB

ICDICD CRT-DCRT-D CRT-P/DCRT-P/D CRT-PCRT-P

≥ ≥ 150ms150ms CRT-DCRT-D CRT-DCRT-D CRT-P/DCRT-P/D CRT-PCRT-P

ICD indications in 2014

Non – ischaemic cardiomyopathyNon – ischaemic cardiomyopathy

NSVT / VT STIM no longer criteriaNSVT / VT STIM no longer criteria

ICD for high risk with normal QRS durationICD for high risk with normal QRS duration

EF < 35% (rather than 30%)EF < 35% (rather than 30%)

ICDs, Biventricular Pacemakers and Combined CRT-D Given NICE guidance and based on Given NICE guidance and based on

contemporary evidence there are going to be a contemporary evidence there are going to be a lot more complex devices implanted into patients lot more complex devices implanted into patients with HF due to LV systolic dysfunctionwith HF due to LV systolic dysfunction

Estimates of increase of 2x more patients Estimates of increase of 2x more patients receiving devicesreceiving devices

Who is going to pay? – at present Specialist Who is going to pay? – at present Specialist Commissioning Group – but they are trying to Commissioning Group – but they are trying to pass back to CCGpass back to CCG

Combined Biventricular Pacemaker and ICD device

Suspected Heart Failure-what to do in general practice 2014 If previous MI refer urgently to cardiologistIf previous MI refer urgently to cardiologist Check BNP - If severely elevated REFER Check BNP - If severely elevated REFER

urgently for an echocardiogram and urgently for an echocardiogram and cardiology opinioncardiology opinion

If moderately elevated refer for cardiology If moderately elevated refer for cardiology opinion within 6 weeksopinion within 6 weeks

Suspected Heart Failure-what to do in general practice 2014 Baseline investigations (FBC,U+E Cr,T4)Baseline investigations (FBC,U+E Cr,T4) Start diuretics (frusemide) + non pharmacological Start diuretics (frusemide) + non pharmacological

RxRx **Anticoagulate with warfarin if in Afib**Anticoagulate with warfarin if in Afib **If echo confirms then Rx with ACE- 1**If echo confirms then Rx with ACE- 1stst and and

then a few weeks later betablockers = start low/go then a few weeks later betablockers = start low/go slow.slow.

**Consider spironolactone (monitoring K+ )**Consider spironolactone (monitoring K+ )

Heart Failure-what a cardiologist can do? Confirm diagnosis in borderline casesConfirm diagnosis in borderline cases Consider other diagnosesConsider other diagnoses Investigate underlying cause – especially if Investigate underlying cause – especially if

there is any revascularisation or valve there is any revascularisation or valve lesion issuelesion issue

Assess 24 hr heart rate in AfibAssess 24 hr heart rate in Afib Assess for DEVICE THERAPYAssess for DEVICE THERAPY

NICE guidance 2010 1.5.1 Referral for more specialist advice1.5.1 Referral for more specialist advice the initial diagnosis of heart failure – valvular the initial diagnosis of heart failure – valvular

heart disease, need for revascularisation, heart disease, need for revascularisation, dysrhythmiasdysrhythmias

Consideration of Device Therapy **Consideration of Device Therapy ** The management of:The management of:

severe heart failure (NYHA class IV)& that does not severe heart failure (NYHA class IV)& that does not respond to treatmentrespond to treatment

heart failure that can no longer be managed effectively heart failure that can no longer be managed effectively in the home setting. in the home setting. [new 2010][new 2010]

**- Dr Pye’s addition 2014**- Dr Pye’s addition 2014

Summary

HF is increasingly prevalent.HF is increasingly prevalent. Diagnosis is problematic use BNP and Echo.Diagnosis is problematic use BNP and Echo. Strong evidence base for the treatment of HF (ACE Strong evidence base for the treatment of HF (ACE

I, BB, SPIRO).I, BB, SPIRO). New Drug – ACE receptor blocker and neprolysin -New Drug – ACE receptor blocker and neprolysin - ARB, & Digoxin cautiously. ARB, & Digoxin cautiously. Increasing use of Complex Device therapy.Increasing use of Complex Device therapy. Need more Community heart failure nurses – just Need more Community heart failure nurses – just

appointed a hospital based specialist nurse in HF – to appointed a hospital based specialist nurse in HF – to improve discharge and reduce readmissionimprove discharge and reduce readmission