Heart Failure 2014
Dr Maurice Pye
Consultant Cardiologist
York District Hospital
Heart Failure 2014
Introduction – numbers – prevalence
prognosis
 NICE Guidelines – 2010 including recent
2014 guidance on complex devices
 Discuss DIAGNOSIS
 Go over management
 Role of Secondary Care

Heart Failure: The Problem 1
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Prevalence 3-20/1000 of the population
(80/1000 in 75+)
Incidence 1/1000 population per year
(10/1000 per year 85+) Median 76 years
Average GP will have 30 pts with HF and
suspect new diagnosis in 10/yr
Heart Failure: The Problem 2
5% of all hospital acute admissions (50%
readmitted within 3/12) and 2% of all hospital
bed IP days
 Expected to rise 50% over next 20 years due to
aging pop
 2-3 visits to the GP per year
 1/3 have prolonged/severe depression
 Annual mortality 30-40% in 1 st year then ~
10% yr
 5yr survival in GP registries = 58% compared
to 93% for age/sex matched population

Heart Failure: Aetiology
What are the causes of heart failure ?
Heart Failure: Aetiology
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Ischaemic heart disease
Hypertension (LVH  risk 15x)
Cardiomyopathy: Alcohol, genetic, chemotherapy
– anthracyclines and herceptin
Valvular heart disease
Arrhythmias – tachycardiomyopathy – particularly
prolonged silent AFib
Pericardial disease – mimics --- Normal echo,
signs of right heart failure – but no intrinsic lung
disease and normal CXR
Diagnosis
How do you diagnose heart failure?
Diagnosis
Diagnosis is difficult
Symptoms, signs and investigations
Symptoms in the diagnosis of heart failure
Symptom
Dyspnoea
Orthopnoea
PND
Oedema
Sensitivity %
Specificity %
66
21
33
23
52
81
76
80
Signs in the diagnosis of heart failure
Clinical findings
Sensitivity
Specificity
Raised JVP
Crackles
Gallop
Oedema
17
29
24
20
98
77
99
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 sensitive
Useful to exclude other causes of SOB
ECHO in the diagnosis of heart failure:
‘Best test’ for assessment LV systolic dysfunction
Of those on HF treatment only 25% have significant LV
Only 25% referred from 1o care have LV systolic dysfunction
Only 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
Specificity
PPV
NPV
76 / 97%
84 / 87%
70 / 16%
98 / 98%
BNP /NT proBNP levels
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+ with age or female
- with obesity
+ in CKD
+ in raised pulmonary artery pressure COPD, PE,
cor pulmonale
+ in AF
+ in valvular heart disease – MR , AS, MS
+ in sepsis
+ in pericardial disease
BNP in LVF some caveats
Atrial fibrillation associated with higher
BNP values so higher cut off = 200pg/ml
increased specificity from 40 to 73% with
redn in sensitivity from 95 to 85%
 Adding BNP to clinical judgement in ER
increased diagnostic accuracy from 70 to
80%
 BNP correctly picked up more than 90% of
patients thought to have low clinical
probability of LVF

BNP caveats
Most dyspnoeic patients with HF have
values above 400 while values below 100
have a very high negative predictive value
for HF as a cause of dyspnea
 In the range between 100 and 400 plasma
BNP concentrations can have lowe
sensitivity or specificity for detecting or
excluding HF

NICE 2010 HF
Diagnosis Key Implementations 1

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Refer patients with suspected heart failure and
previous myocardial infarction (MI) urgently, to
have transthoracic Doppler 2D echocardiography
and specialist assessment within 2 weeks. [new
2010]
A BNP level above 400 pg/ml (116 pmol/litre) or
an NTproBNP level above 2000 pg/ml (236
pmol/litre) urgently, to have transthoracic Doppler
2D echocardiography and specialist assessment
within 2 weeks. [new 2010]
NICE 2010 HF
Diagnosis Key Implementations 2

Refer patients with suspected heart failure
and a BNP level between 100 and
400 pg/ml (29–116 pmol/litre) or an
NTproBNP level between 400 and
2000 pg/ml (47–236 pmol/litre) to have
transthoracic Doppler 2D echocardiography
and specialist assessment within 6 weeks.
[new 2010]
NICE 2010 HF
Diagnosis Key Implementations 3


a serum BNP level less than 100 pg/ml
(29 pmol/litre) or an NTproBNP level less than
400 pg/ml (47 pmol/litre) in an untreated patient
makes a diagnosis of heart failure unlikely
the level of serum natriuretic peptide does not
differentiate between heart failure due to left
ventricular systolic dysfunction and heart failure
with preserved left ventricular ejection fraction.
[new 2010]
Caveats in role of ECHO -NICE

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1.1.1.7 Perform transthoracic Doppler 2D
echocardiography to exclude important valve
disease, assess the systolic (and diastolic)
function of the (left) ventricle, and detect
intracardiac shunts. [2003]
1.1.1.8 Transthoracic Doppler 2D
echocardiography should be performed on
high-resolution equipment, by experienced
operators trained to the relevant professional
standards. Need and demand for these studies
should not compromise quality. [2003]
1.1.1.9 Ensure that those reporting
echocardiography are experienced in doing so.
[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
your HF patients ?
General measures for heart failure

Risk factor management
 Smoking,
obesity, lipids, HT, DM,
 Alcohol


Salt reduction( 3g/day) ??
Avoid
 Calcium

Other


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antagonists, NSAIDs, Anti-arrhythmics
Flu vacc, Pneumococcal vacc, OPD/HOME F/U
Exercise programme
Selected patients
 Control AF,
anticoagulation, revascularization
Drug treatment for heart failure
Which agents prolong life?
Which agents do you use?
Drug treatment for heart failure

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Diuretics
ACE inhibitors
Beta blockers
Spironolactone
Angiotensin II receptor blockers (ARBs) (sartans)
Digoxin AF +- sinus rhythm
Hydralazine and nitrates (if ACE or sartans not
tolerated)
Warfarin
NEW PARADIGM TRIAL – ACE- neprolysin-
NICE 2010 Heart Failure
Key Implementation

1.2.2.2 Offer both angiotensin-converting
enzyme (ACE) inhibitors and beta-blockers
licensed for heart failure to all patients with
heart failure due to left ventricular systolic
dysfunction. Use clinical judgement when
deciding which drug to start first. [new
2010]
ACE I/ARB: How to do it

WHO
 All
patients with HF
 Care: K+ > 5.5 or Cr >200 or Ur >12 or Na 130 or
SBP < 100 or > frusemide 80 mg od

WHEN
 Once

HF confirmed (Ideally echo LV function)
HOW
K+ supp and NSAID and warn re hypotension
 U&E’s/K+ week 1 and 4 and ? 6 monthly after
 Low dosemid 1/52. Target dose 1/12
 Refer if adverse effects as above
 Stop
NICE 2010 ACE inhibitors
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ACE inhibitors (first-line treatment)
1.2.2.5 Start ACE inhibitor therapy at a low dose
and titrate upwards at short intervals (for example,
every 2 weeks) until the optimal tolerated or target
dose is achieved. [2010]
1.2.2.6 Measure serum urea, creatinine,
electrolytes and eGFR at initiation of an ACE
inhibitor and after each dose increment[2010]
Beta-blockers: How to do it

WHO:
 For
all with mild/moderate HF (NYHA II/III)
 HR>60 SBP>100
 Clinically stable >4/52, no AMI/UA >3/12

WHEN
 Once

Euvolaemic
HOW
 Bisoprolol
1.25 (1/52) 2.5(1/52)3.75(1/52)
5 (4/52) 7.5 (4/52) 10 mg
NICE guidance Beta blockers

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Offer beta-blockers licensed for heart failure to all
patients with heart failure due to left ventricular
systolic dysfunction, including:
older adults and
patients with:
 peripheral
vascular disease
 erectile dysfunction
 diabetes mellitus
 interstitial pulmonary disease and
 chronic obstructive pulmonary disease (COPD)
without reversibility. [new 2010]
NICE guidance Beta blockers


1.2.2.8 Introduce beta-blockers in a 'start low, go
slow' manner, and assess heart rate, blood
pressure, and clinical status after each titration.
[2010]
1.2.2.9 Switch stable patients who are already
taking a beta-blocker for a comorbidity (for
example, angina or hypertension), and who
develop heart failure due to left ventricular
systolic dysfunction, to a beta-blocker licensed for
heart failure. [new 2010]
Spironolactone: How to do it

WHO
 All
patients with moderate/severe HF
 Care K+ > 5.0 or Cr >221

WHEN
 Once

stabilized on ACE I
HOW
 Dose
25 mg/day
 U&E’s/K+ week 1 and 4 and ? 3-6 monthly after
Aldosterone Antagonist NICE 2010

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Aldosterone antagonists (second-line treatment)
See also recommendations 1.2.2.3 and 1.2.2.4.
1.2.2.10 In patients with heart failure due to left
ventricular systolic dysfunction who are taking
aldosterone antagonists, closely monitor
potassium and creatinine levels, and eGFR. Seek
specialist advice if the patient develops
hyperkalaemia or renal function deteriorates[22].
[new 2010]
Lives saved with Rx
TRIAL
HOPE
SOLVD-P
SOLVD-R
MERIT
CIBIS
RALES
COPERNICUS
Lives saved/1000/year
<1
7
17
38
42
52
70
Heart failure - whats on the horizon
New Ace
inhibitor Neprolysin
inhibitor PARADIGM HF study
ECS 2014
Previous Guidance TA95 2006
For Complex devices CRT or ICD

ICD if;
 LVEF
<35%, NSVT on Holter AND positive V-
STIM

OR
 LVEF
<30%
 QRS >120ms
No worse than NYHA 3
 High risk condition
 Secondary prevention

Previous Guidance TA120 2007

CRT if
 NYHA 3
or 4
 Sinus Rhythm
 Optimal medical Rx
 QRS > 150ms OR 120-149ms with echo
dyssynchrony
 EF <35%
More Data since 2007

ICD
 DEBUT
2003
 DINAMIT 2004
 SCD-HeFT 2005
 IRIS 2009
No benefit early post MI
 Benefit in non - ischaemic cardiomyopathy

More Data

CRT
 RETHINQ
2007
 PROSPECT 2008
 REVERSE 2008
 MADIT CRT 2009
 RAFT 2010
 ECHO-CRT 2013

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Lack of benefit (harm) in normal QRS, benefit
in NYHA 1 and 2
Echo dyssynchrony assessment unhelpful
NICE GUIDANCE 2014
ANY HEART FAILURE, LVEF ≤ 35%
QRS
duration
NYHA 1
NYHA2
NYHA3
NYHA4
<120ms
ICD IF THERE IS A HIGH RISK OF SCD
NO DEVICE
120-149ms,
no LBBB
ICD
ICD
ICD
CRT-P
120-149ms
with LBBB
ICD
CRT-D
CRT-P/D
CRT-P
≥ 150ms
CRT-D
CRT-D
CRT-P/D
CRT-P
ICD indications in 2014

Non – ischaemic cardiomyopathy

NSVT / VT STIM no longer criteria

ICD for high risk with normal QRS duration

EF < 35% (rather than 30%)
ICDs, Biventricular Pacemakers and
Combined CRT-D
Given NICE guidance and based on
contemporary evidence there are going to
be a lot more complex devices implanted
into patients with HF due to LV systolic
dysfunction
 Estimates of increase of 2x more patients
receiving devices
 Who is going to pay? – at present Specialist
Commissioning Group – but they are trying
to pass 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 cardiologist
 Check BNP - If severely elevated REFER
urgently for an echocardiogram and
cardiology opinion
 If moderately elevated refer for cardiology
opinion within 6 weeks

Suspected Heart Failure-what to do
in general practice 2014
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Baseline investigations (FBC,U+E Cr,T4)
Start diuretics (frusemide) + non pharmacological
Rx
**Anticoagulate with warfarin if in Afib
**If echo confirms then Rx with ACE- 1st and
then a few weeks later betablockers = start low/go
slow.
**Consider spironolactone (monitoring K+ )
Heart Failure-what a cardiologist
can do?
Confirm diagnosis in borderline cases
 Consider other diagnoses
 Investigate underlying cause – especially if
there is any revascularisation or valve lesion
issue
 Assess 24 hr heart rate in Afib
 Assess for DEVICE THERAPY

NICE guidance 2010
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1.5.1 Referral for more specialist advice
the initial diagnosis of heart failure – valvular
heart disease, need for revascularisation,
dysrhythmias
Consideration of Device Therapy **
The management of:
 severe
heart failure (NYHA class IV)& that does not
respond to treatment
 heart failure that can no longer be managed effectively
in the home setting. [new 2010]
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**- Dr Pye’s addition 2014
Summary
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HF is increasingly prevalent.
Diagnosis is problematic use BNP and Echo.
Strong evidence base for the treatment of HF (ACE I,
BB, SPIRO).
New Drug – ACE receptor blocker and neprolysin ARB, & Digoxin cautiously.
Increasing use of Complex Device therapy.
Need more Community heart failure nurses – just
appointed a hospital based specialist nurse in HF – to
improve discharge and reduce readmission