Heart Failure: From Failure to Success

1. Heart Failure: From Failure to Success Dr. Alison Seed Consultant Cardiologist

2. Failures? • In diagnosis • In routine management • In advanced management • To address the personal AND financial burden

3. Diagnosis........... 1.Pushing the boundaries: Improving services for people with heart failure. HCC(CHAI ) 2007 2. State of healthcare: Improvements and challenges for services in England and Wales. HCC (CHAI) 2007 3. Blackpool GP HF register data: Brian Harrop, Blackpool PCT

4. Routine management..........

5. Advanced management........

6. Personal and financial burden... • Poor prognosis • 10-50% mortality per year • Poor quality of life • Poor exercise tolerance • >30% depressive illness • Frequent hospital admission • 5% of acute medical admissions • 40% death /readmission in one year • Long length of stay • > 8 days • 2% of in patient bed days 2% total annual NHS expenditure

7. Cost

8. Hospital admission length of stay

9. Healthcare Commission 2007 • HF diagnostic services poor • Diagnosis difficult because symptoms non specific and physical signs not obvious • Early diagnosis leads to appropriate life saving and symptom reducing treatment • Limited access to heart failure specialists • Need to target advanced treatments at high risk patients • Rates of hospitalisation remain high Healthcare Commission. Pushing the boundaries: improving services for people with heart failure. London Healthcare Commission, 2007

10. Are we offering.......... Advanced Care or Palliative Care ........... to our Patients with Heart Failure?

11. Currently (2009)…. • Inequitable care • Only for the symptomatic patient seeking help • No more than Crisis management for the majority Palliative Care that could be better !!

12. National drivers • Quality Outcomes Framework • ‘Advancing Quality’ (NW SHA) • National HF database • Darzi report • Equitable, efficient, patient centred care • Health improvement (outcomes and quality) • Adherence to best practice (NICE, NSF) • Financial climate • Avoid hospital admission • Manage chronic disease in primary care

13. Our aim…. ‘Best care’ whenever and wherever patients require it ............ • Not currently seeking attention • Not yet diagnosed • With confirmed diagnosis • New presentation • In Primary Care with symptoms • Hospital admission(s) • With severe heart failure

14. Our aim.... To demonstrate that optimal care is cost saving...................

15. Failures? Diagnosis • Routine management • Advanced management

16. Definition: The first problem European society of Cardiology: ‘typically breathlessness or fatigue, either at rest or during exercise, or ankle swelling; and objective evidence of cardiac dysfunction at rest (usually on echocardiography)’

26. New York Heart Association NYHA > II Further investigation required

27. BNP • Brain-type Natriuretic Peptide (BNP) is a hormone, secreted in the ventricular myocardium during periods of increased Atrial and ventricular wall tension • It is the most powerful marker of cardiovascular morbidity and mortality including sudden death • An elevated BNP indicates that the heart or kidneys are not working well but does not tell exactly why

28. NICE Guidance 2010

29. Heart Failure Diagnostic Clinic One stop Within 2 weeks

30. Heart Failure Diagnostic Clinic Comprehensive specialist assessment • History/ examination • Echocardiogram • Consideration of need for further investigation • Angiogram, TOE, stress test • Management plan • Lifestyle • Pharmacological • Non pharmacological • Device therapy • Patient education / engagement

31. HF referral poster • AQ data

32. Failures? Diagnosis • Advanced management • Routine management

33. Failures? Diagnosis • Advanced management • Routine management

34. Right AtrialLead Right VentricularLead Biventricular Pacemakers

36. ECG • P wave • QRS duration

39. Right AtrialLead Left VentricularLead Right VentricularLead Biventricular Pacemakers

42. Biventricular Pacemakers

43. Biventricular Pacemakers 36% reductionin All Cause Death / CVS death /Hospitalisation CARE – HF: Cleland et al, NEJM, 2005

44. Referral for CRT from North Lancs/ Blackpool

45. Transplant vs. medical Rx Butler et al. J Am Coll Cardiol, 2004

46. Cardiopulmonary exercise testing

47. Survival following cardiac transplant 1 year: 85% 5 years: 73% 10 years: 58% www.uktransplant.org.uk

48. Mechanical support: Ventricular assist devices Outflow: Ao Inflow: LV/LA

49. Bridge to transplant • Bridge to recovery • Destination therapy • Who should receive a VAD as bridge to transplant?

50. Heart Failure Service - Blackpool Timely and accurate diagnosis • One stop diagnostic clinic Appropriate/safe/rapid referral pathways • Identify high risk patients • BNP Efficient and effective clinical care • Treatment optimisation (NICE) • Non pharmacological intervention (CRT / ICD, LVAD, Tx) • Communication , Communication, Communication