Heart failure Achieving Excellence in Heart Failure care

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Heart failureAchieving Excellence in Heart
Failure care

• Naguib Hilmy GPSI Milton Keynes
• John Parnell Manager HealthMK

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One-year survival rates, heart failure and major
cancers compared, mid-1990's, England and Wales
ONS (2001) Cowie MR et al (2000) Heart 83
505-510
www.heartstats.org
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Prevalence of heart failure by age and sex, most
deprived and least deprived areas compared,
1998, England and Wales
Ellis C et al (2001) Health Statistics Quarterly
11 17-24
www.heartstats.org
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Health MK is a practice based commissioning
collaborative with 26 member practices and
serving a population of gt245,000 (total MK
population gt250,000).
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MK Community cardiac service

• 2 GPSIs, Admin, HCAs Practice nurses
• GPSI in North MK Dr Mahendran
• MKPCT CHD Lead
• Support from MK NHS trust Cardiology
• Dr David Gwilt . Dr Attila Kardos

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Patients on database 2558

• Sept 08

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24 Hour ECGs- Event recorders

• 2008 400
• 2007 356
• 2006 252
• 2005 136
• 2004 49

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Registers
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North Central London sector-wide Heart failure
QOF data National estimated prevalence
2.3National recorded prevalence 1.8
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Heart Failure 2 (Echo)
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Heart Failure 3 -ACEI
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Audit

• PCT is providing help to practices to look at
  their registers.
• We have trialled a series of data audits and
  actions to pick-up missing and lost patients from
  the Heart Failure Registers. In both trial
  practices patients have been added to the
  registers.
• The audits are being rolled out, either to be
  done by the practice or by PCT Heart Failure
  Nurse facilitator

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Registers

• Change in 2007 from implicit coding to explicit,
  GPs or CHD nurse involvement now needed.
• OPD letters rarely stated Heart Failure as a
  diagnosis.
• Registration is geared to providing therapeutic
  management.

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Support

• The process involves checking and advising
  summarisers of the read code issues, and identify
  any learning issues for incorporation into
  training.
• Heart Failure discussed with practices CHD nurse
  to ensure HF patients are seen. In this process
  we will also identify any training needs.
• Updated Heart Failure Manual is being produced.

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Heart Failure Rehabilitation Service

• A new service will start in May 2009 (probably)
  which will provide exercise and psychological
  support for patients with a new diagnosis of
  Heart Failure.
• Direct referral from GPs, Practice Nurses and
  MKFT.
• Direct referral from HF Rehab to Community
  Cardiology Services.
• With a pathway to provide long term self-care
  support.

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Experience from initial searches at pilot
practices

• Until recently there was no universal definition
  for Heart Failure and a complicated system of
  read coding has evolved for QOF.
• GMS QOF HF indicators include patients with -
  LVSD-LVDD
• About half of the patients with measurable left
  ventricular dysfunction in the MONICA and ECHOES
  studies - had no symptoms.

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Echocardiogram

• Data missing ejection fractions and
  ventricular function status.
• For QOF purposes echo code needs to be linked to
  G58 codes.

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Method of Case Review

• Loop Diuretics search (exclusions), problem
  lists, medical history, current therapy,
  echocardiogram results if available.
• Some empirical management of patients with
  symptoms, especially elderly patients.
• Healthcare Commission found that nationally,
  only 33.4 of patients discharged with heart
  failure were prescribed beta-blockers and issues
  remain over follow up and titration of
  medication.  

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LVD/ Heart Registers

• Access To diagnostics
• Coding
• Co-morbidities
• Has the patient been given the diagnosis?
• Weak Heart 'fluid on your lungs - your heart
  is not pumping hard enough
• a diagnosis of 'heart failure' was rarely
  communicated to patients to avoid causing
  anxiety

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Heart Failure 1 (READ2)

• Heart Failure (G58)
• Rheumatic Left ventricular failure (G1yz1)
• NYHA classification class I (662f)
• NYHA classification- class II (662g)
• NYHA classification class III (662h)
• NYHA classification- class IV (662i)

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Codes not included as heart failure

• Dilated cardiomyopathy
• Ischaemic cadiomyopathy
• Left ventricular systolic dysfunction
• Left ventricular diastolic dysfunction

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Heart Failure 2 Echocardiography

• Echo shows LVSD 585f
• Echo shows LVDDF 585g
• U-S heart scan 5853
• Echo abnormal 58531
• Echo equivocal 5C20
• Echo requested 33BD
• Referral for echo 8HQ7
• Echo abnormal R1320
• Ultrasound cardiog abn R1322

• Ref to cardio sp int gp 8H4R
• Priv ref to cardiologist
• 8HVJ
• Cardiological referral
• 8H44
• Angiocardiography
• 5531, 5532, 5533,5538
• 79380, 79382

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Should every body with suspected heart failure
have an Echocardiogram?How many?How often?
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• If investigation is limited to patients with more
  definite symptoms and signs of heart failure,
  fewer than 50 of cases will be identified and a
  large number of patients with mild symptoms will
  be missed EPICA

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EPICA

• Abnormal ECG 81 sensitivity
• Abnormal CXR 57 sensitivty
• 25 of CHF patients had normal ECG or CXR

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Heart failure is most unlikely in a patient with
a normal ECG or normal plasma concentration of
BNP or NT-proBNP given the high sensitivity of
these tests

• The sensitivity of BNP may be as high as 90-97
  in patients presenting with new symptoms ,
  depending on assay used cut off point
• The sensitivity of ECG is as high as 94

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Tests used to diagnose significant
CHD Treadmill test sensitivity of 68,
specificity of 77 Nuclear test sensitivity of
81, specificity of 85-95 Portable Echo (
LVSD) sensitivity 96,
specificity 98
NPV 99.6 PSA
for Prostate Cancer gt4
sensitivity 7079
specificity
5990 one in 8 men with PSA lt 4 will have
prostate cancer
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Predictive Value

• BNP (Biosite)
• NPV 88.2 at 40pg/ml
• Avoid 51 referrals but miss 6 with LVSD
• PPV 55 at 40pg/ml

• NT pro-BNP (Roche)
• NPV 97.3 at 150pg/ml
• Avoid 37 referrals miss 1 with mild LVSD
• PPV 52 at 150pg/ml

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What proportion of patients referred for
suspected HF have heart failure ?

• 29 Cowie 1999
• 5-8 in asymptomatic patients ?

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Suspected Heart failureSOB , Fatigue, Oedema
Clinical assessment
NT-ProBNP
ECG
Normal Heart failure unlikely
Abnormal Echocardiogram
Murmurs Blackouts Echo monitors
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First 100 NT-ProBNP( Jan to June 08)
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• Results of less than 60 pg/ ml 21 patients
• Results of less than 100pg/ml 37 patients
• Results of less than 150pg/ml 39 patients
• Results of less than 200 pg/ ml 54 patients
• Results of less than 300 pg/ml 66 patients
  
• Results of 300 to 500 pg/ ml 6
  patients
• Results of 500 to 1000 pg/ ml 12 patients
  
• Results over 1000 pg/ml 16
  patients
• Results over 3000 pg/ml 5
  patients

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RESULTS

• 45/100 did not require a new or repeat
  Echocardiogram.
• Heart failure with evidence of LVSD
• eight
  patients.
• Heart failure due to diastolic dysfunction
  
• twelve
  patients.

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16 patients with readings gt1000 pg/ ml

• 8 had LVSD,
• 3 LVDD,
• 3 Aortic stenosis, one had urgent AVR
• 1 Significant MR

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12 patients with readings between 500 1000 pg/ml

• 4 had diastolic dysfunction
• 1 known heart failure with normal EF, MV repair
  AF

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LVSD

• EF 50 388 2025 pg/ml
• EF 40 1929 1468 pg/ml
• EF 30 2435 , 2526 gt 3000 pg/ml
• EF 26 gt3000 pg/ml

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ECGs

• Normal 51
• Abnormal 46
• Not available 3

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Echos done 54

• Normal ( 11 patients) levels (pg/ml)
• lt60 x5, 60, 81, 165, 187, 278, 336
• LVSD ( 8 patients ) levels (pg/ml)
• 388 (AF, EF 50), 1468, 1929, 2025. 2435,
  2526, gt 3000 x2

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LVDD with or without heart failure

• (12 patients) levels (pg/ml)
• 74, 92, 273, 293, 332, 513, 613, 680, 772,
  1057, 1239, gt 3000

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20 patients Other abnormalities

• including mitral regurgitation, aortic valve
  disease, small pericardial effusion, left
  ventricular hypertrophy etc

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Hospital referrals

• 2 patients were admitted to hospital one on
  diagnosis one with increasing symptoms
• 6 patients already attending cardiology
• 11 patients referred to cardiology
• 3 AS, 1 MR, 1 PAF, 1 for pacing

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45 Echos were not done or repeated

• 6 were not repeated,
• One had been undertaken by hospital
• 15 patients COPD, asthma, chest infection
• 4 patients advanced cancer
• Massive Ascites due to cirrhosis, panic attacks,
  dementia , glitazone oedema

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Limitations

• This is not an academic study no blinding
• Some of these patients may not have been referred
  to cardiology
• Some patients had previous echos
• Patients who had Echocardiogram followed by
  NT-proBNP were included

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Conclusions

• NT-pro-BNP near patient testing combined with
  clinical assessment and ECG by PSI in the
  community appear to offer a method for prompt
  risk assessment for patients presenting with
  suspected heart failure

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• It helps to triage and prioritise patients that
  need immediate echocardiography and reassure
  those who do not require an echocardiogram and
  differentiate the ones that can have routine
  echocardiogram
• We should continue to listen to our patients and
  not dismiss the value of careful clinical
  evaluation

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Treatment Approach for the Patient with Heart
Failure
Stage A At high risk, no structural disease
Stage B Structural heart disease, asymptomatic
Stage D Refractory HF requiring specialized
interventions
Stage C Structural heart disease with
prior/current symptoms of HF

• Therapy
• Treat Hypertension
• Treat lipid disorders
• Encourage regular exercise
• Discourage alcohol intake
• ACE inhibition

• Therapy
• All measures under stage A
• ACE inhibitors in appropriate patients
• Beta-blockers in appropriate patients

• Therapy
• All measures under stage A
• Drugs
• Diuretics
• ACE inhibitors
• Beta-blockers
• Digitalis
• Dietary salt restriction

• Therapy
• All measures under stages A,B, and C
• Mechanical assist devices
• Heart transplantation
• Continuous (not intermittent) IV inotropic
  infusions for palliation
• Hospice care

Hunt, SA, et al ACC/AHA Guidelines for the
Evaluation and Management of Chronic Heart
Failure in the Adult, 2001
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Problem solving

• Harmful substances
• -Smoking, Excess alcohol
• - Inappropriate type or dosing of B blocker
• - NSAIDS, Coxibs, Glitazones
• Community Matrons, Heart Failure Nurses
  

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Seattle Heart Failure Model Calculator

• http//depts.washington.edu/shfm/app.php?accept1
  enterEnter

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