Diagnosis and Management of Chronic Heart Failure

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Diagnosis and Management of Chronic Heart Failure

• James Clarkson-Feb 2007

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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

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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

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Causes of Heart Failure

• Commonest cause of LV systolic dysfunction-coronar
  y artery disease
• Hypertension (partly diastolic dysfunction)
• Arrhythmias
• Valvular
• Cardiomyopathy-
• Toxic-alcohol/drugs
• Undilated-obstructive/restrictive
• Dilated-?myocarditis/idiopathic

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Causes ..continued

• Congenital
• Pulmonary disease/cor pulmonale
• Non-cardiac / systemic
• Thyroid
• Pregnancy
• Anaemia

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Symptoms

• Dyspnoea
• 66sensitivity 52specificity
• Paroxysmal Nocturnal Dyspnoea
• 33 sensitivity 76spec
• Oedema
• 23 sensitivity 80spec
• Orthopnoea
• 21 sensitivity 81spec

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Signs

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

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Basic Investigations

• Bloods FBC, UE, 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

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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!

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Other Tests

• MUGA radio nuclide scan for ejection fractions
• Thallium perfusions scans for hibernating
  muscle and ?revascularisation
• PET and dobutamine stress tests for ischaemia

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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

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BNP - Benefits

• Blood test quicker ??cheaper than echo
• Differentiate cardiac vs. respiratory
  breathlessness
• Monitor treatment
• ?Prognostic indicator
• ?Asymptomatic detection of those at risk

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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

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Algorithm
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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 gt6g/day
• Caution regarding dietary advice

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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

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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

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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 -UE 2-weekly and at least
  6-monthly

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Drug TreatmentContinued

• 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

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Other Treatment

• Aspirin/stains if needed
• Flu vaccine (Contract alert!)
• Pneumococcal vaccine
• ?Depression screening (HAD score)

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Key References

• SIGN Guideline 95 www.sign.ac.uk
• NICE Clinical Guidelines 5
• Dobbs F Struthers A BMJ 2000321895 for BNP
  meta-analysis