Heart Failure Care in Primary Care Setting

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Heart Failure Care in Primary Care Setting

• Jo Noble
• Heart failure nurse, clinical lead.
• Dawn Walsh,
• Heart failure nurse.

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Aims

• Provide an overview of
• Who to refer and when
• What our role is
• Provide an understanding of heart failure care
  from the primary care perspective
• Review and discuss clinical scenarios and
  possible treatment options.

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NICE 2003 recommendations for diagnosis of heart
failure
Suspected heart failure History, signs and
symptoms
Other recommended tests CXR, UEs, Creatinine,
eGFR, FBC, TFTs, glucose, lipids, urinalysis,
Peak flow and spirometry

• Seek to exclude heart failure
• 12 lead ECG
• ???BNP

One or more abnormal undertake echo
Both normal HF unlikely Consider alternative
Abnormal assess HF severity, aetiology Precipita
ting exacerbating factors, Type of cardiac
dysfunction Correctable causes must be
identified Consider referral.
No abnormality detected HF unlikely, but if doubt
persists consider diastolic dysfunction and
referral for specialist assesment.
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BNP B-type natriuretic peptide

• Released from ventricular myocytes
• Caused by excessive stretch
• Usually from left ventricle but can be from right
• Any cause of ventricular strain results in BNP
  release
• High BNP always indicates a struggling heart
  but not necessarily what we label heart failure

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New York Heart Association Grading

• Grade I No limitations. Ordinary activity does
  not cause fatigue or breathlessness
• Grade II Slight limitation of physical activity.
• Comfortable at rest. Ordinary activity causes
  fatigue, breathlessness.
• Grade III Marked limitation of ordinary
  activity.
• Grade IV No physical activity without
  discomfort. Symptoms of CHF even at rest.

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Who refers to us?

• Cardiologist, ORH / HGH
• Medical outpatient clinics
• Heart failure nurse, ORH
• GP
• CCU / Cardiology / ICD clinic / medical ward
  (increasing numbers now)
• DN / case manager
• (GP must be aware)

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Who to refer?

• Referral Criteria
• Left Ventricular Systolic Dysfunction must be
  confirmed by echocardiogram.
• New York Heart Association (NYHA) classification
  grade III/IV. (may take NYHA I and II if
  suitable for clinic)
• Hospital admission with heart failure within last
  6 months
• Requiring palliative care for heart failure.

• ?? Exclusion criteria
• Life expectancy estimated at less than six months
  as a result of other illness
• ST elevation MI with associated LVF within the
  last 3 months. (Will be followed up by cardiac
  rehabilitation team).

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Referral from GP, secondary care, district nurse
or case manager
Meets referral criteria.
yes
no

• Current support available-
• Optimisation of medical therapy as required with
  appropriate blood chemistry monitoring
• Symptom management
• Lifestyle advice / education
• Referral to other services / agencies as
  necessary
• Psychological support to patient / carer.
• Service input will be decided upon individually
  after the initial visit

HFN has phone contact within 3 working days
Suggest referral to other service if appropriate
Patient held record given to patient including
HFN contact details, NICE guidelines, BHF
booklets as appropriate.
HFN undertakes home visit within 10 working days
for full physical / social assessment.
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One visit for education only and information
giving
Discharge from the service is when- Optimum
medical therapy achieved or maximum dose
tolerated Care package in place Haemodynamically
stable Maximum symptom benefit achieved.
Letter or contact to GP/consultant and any other
required parties within 7 working days of each
assessment if changes or update required.
Several visits for titration of medication or
patient review until optimum treatment levels
obtained or patient stable.
Patients who require close monitoring during
up-titration of medical therapy will be reviewed
as required for as long as required. This may be
via telephone or home visit.
Discharge summary to GP / PN / DN / case manager
and any other appropriate involved HCP with
recommended plan for future maintenance
Methods of re-referral include - patient or
family member self re-refer, GP, nursing or other
HCPs can re-refer a phone call or visit will
be undertaken to establish the input required and
the outcome communicated back to appropriate
involved staff.
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Our support

• Monthly meetings with Dr Jeremy Dwight and Dr Ian
  Arnold, Cardiologists ORH NHS Trust.
• Easy access to other cardiologists if needed.
• Ability to assist prompt referral to cardiologist
  if needed in negotiation with GP. This sometimes
  is enough to prevent an emergency admission.

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Meds info if needed???
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Decompensation

• Non compliance
• Inadequate therapy
• Uncontrolled hypertension
• Cardiac arrhythmias
• Environmental factors, eg stress
• Exceeding fluid allowance
• Ignoring weight increase / increasing oedema
• Chest infection (or other metabolic disturbance)
• NSAIDs ie voltarol, ibubrofen
• Myocardial Infarction
• Endocrine disorders (thyrotoxicosis)

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Primary vs secondary care presentation and
treatment

• Secondary care
• Emergency
• Make a diagnosis
• Treat the problem
• Discharge

• Primary care
• Slow onset
• Different presentations
• Slower process for diagnosis
• Start and titrate medications
• Education and secondary prevention
• Self management
• Prevention of admission
• End of life care

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In summary we will

• Assist with management of patients heart failure
  through close liaison with referring team and GP.
• Support educate patient / family / carers
  encouraging self management reinforcing need
  for early intervention.
• Support, educate and liaise with the MDT.
• Refer to other agencies as necessary.
• Keep patient on caseload, seeing at home or in HF
  clinic until condition stable or optimal drug
  therapy achieved or for ongoing telephone
  support.

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• Assist with up-titration of medication with
  associated clinical/biochemistry monitoring.
• Order home oxygen where appropriate.
• Carry out joint home visits ie Case Manager / DN
  / GP / Respiratory / MacMillan Nurses.
• Be involved at end-stage / in palliative care
  situation / liaise with palliative care services.
• Continually review and reinforce lifestyle advice
  if required.
• Assist , if requested, with case finding and
  establishing practice based HF clinics including
  education of practice nurses.