Diagnosis and Management of Chronic Heart Failure

1. Diagnosis and Management of Chronic Heart Failure James Clarkson-Feb 2007

2. Heart Failure-??Hot Topic?? GMS contract-chronic disease Evolving evidence & guidelines SIGN 95 February 2007 NICE 2003 High Mortality – 25% in Scotland at 5 years Common-?incidence rising with ageing population surviving more of their cardiac events

3. Definition of Heart Failure complex syndrome which can result from any structural or functional cardiac or non-cardiac disorder that impairs the ability of the heart to support a physiological circulation

4. Causes of Heart Failure Commonest cause of LV systolic dysfunction-coronary artery disease Hypertension (partly diastolic dysfunction) Arrhythmias Valvular Cardiomyopathy- Toxic-alcohol/drugs Undilated-obstructive/restrictive Dilated-?myocarditis/idiopathic

5. Causes ..continued Congenital Pulmonary disease/cor pulmonale Non-cardiac / systemic Thyroid Pregnancy Anaemia

6. Symptoms Dyspnoea 66%sensitivity 52%specificity Paroxysmal Nocturnal Dyspnoea 33% sensitivity 76%spec’ Oedema 23% sensitivity 80%spec’ Orthopnoea 21% sensitivity 81%spec’

7. Signs JVP, fast pulse, 3rd heart sound, peripheral oedema, creps, displaced apex Generally poor sensitivity but good specificity

8. Basic Investigations Bloods – FBC, U&E, LFT, glucose, thyroid Urinalysis Chest x-ray ?? Spirometry ECG (contract alert!) LVH, LBBB, AF, pathological Q waves and “non-specific” ST/T changes all suggestive but non-specific ? Good negative predictive value if normal

9. Echocardiography Echo (2-d with Doppler) probably routine “gold standard” in current practice and can identify systolic & (?)diastolic dysfunction and possible aetiologies Limitations Availability/time/expense ?Operator/patient dependent ?Diastolic dysfunction Contract Alert!

10. Other Tests MUGA radio nuclide scan for ejection fractions Thallium perfusions scans for “hibernating” muscle and ?revascularisation PET and dobutamine stress tests for ischaemia

11. BNP Brain-type Natriuretic Peptide (and NT-proBNP metabolite) release by myocytes in response to pressure and volume-overload BNP levels rise (and fall) with worsening (or improving) haemodynamics Sensitivity 86-97% Specificity lower Good negative predictive value

12. BNP - Benefits Blood test quicker & ??cheaper than echo Differentiate cardiac vs. respiratory breathlessness Monitor treatment ?Prognostic indicator ?Asymptomatic detection of those at risk

13. BNP - Pitfalls Half Life 2 hours for NT-proBNP Not specific – raised anyway by most causes of heart failure plus diabetes, renal/hepatic impairment, sepsis, beta-blockers, digoxin Normal values age/sex/race dependent and still being debated Expense-?cost £17 per assay locally

14. Algorithm

15. Treatment-Lifestyle Alcohol –conflicting evidence from abstinence benefits Stop smoking Exercise-evidence for graded,low intensity, home based walking programme Salt restriction ??benefit and conflicting evidence but not >6g/day Caution regarding dietary advice

16. Drug Treatment ACE Inhibitor (Contract Alert!) Morbidity/mortality benefit and consider in all patients Angiotensin II antagonist (ARB) Use if intolerant of ACE I CHARM study indicated role in addition to ACE I but probably under specialist advice if still symptomatic ?Especially useful for diastolic dysfunction

17. Drug Treatment… Continued Beta-blockers (carvedilol/bisoprolol) Mortality and symptomatic benefit Nebivolol effective in elderly May temporarily worsen heart faliure Contraindications Diuretics Evidence mostly for symptomatic benefit Loop diuretic first line and can add thiazide

18. Drug Treatment …Continued Aldosterone antagonists RALES (spironolactone) and EPHESUS(eplerenone-less gynaecomastia) showed better survival and fewer admissions Probabaly specialist supervision if symptomatic despite ACE I +/- ACE II +/- Beta Blocker Beware potassium -U&E 2-weekly and at least 6-monthly

19. Drug Treatment…Continued Digoxin Use if AF Can use if in sinus and symptomatic despite optimum tolerated Rx Beware dig’ toxicity and hypokalaemia Hydralazine/Nitrates If ACE I/ACE II contraindicated Maybe useful in Afro-Carribeans

20. Other Treatment Aspirin/stains if needed Flu vaccine (Contract alert!) Pneumococcal vaccine ?Depression screening (HAD score)

21. Key References SIGN Guideline 95 www.sign.ac.uk NICE Clinical Guidelines 5 Dobbs F Struthers A BMJ 2000:321:895 for BNP meta-analysis