Heart Failure: From Failure to Success

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Heart Failure From Failure to Success

• Dr. Alison Seed
• Consultant Cardiologist

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Failures?

• In diagnosis
• In routine management
• In advanced management
• To address the personal AND financial burden

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Diagnosis...........
Prevalence gt45yrs
National (expected) 2.3
National Blackpool PCT (recorded) 1.8 (0.19-5)
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
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Routine management..........
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Advanced management........
Implant rate / million population / year Implant rate / million population / year Implant rate / million population / year Implant rate / million population / year Implant rate / million population / year
USA average EU average UK target UK average Lancs. South Cumbria 2006
ICD 610 160 100 46 28
Bi V PPM 275 75 140 56 58
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Personal and financial burden...

• Poor prognosis
• 10-50 mortality per year
• Poor quality of life
• Poor exercise tolerance
• gt30 depressive illness
• Frequent hospital admission
• 5 of acute medical admissions
• 40 death /readmission in one year
• Long length of stay
• gt 8 days
• 2 of in patient bed days

2 total annual NHS expenditure
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Cost
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Hospital admission length of stay
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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
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• Are we offering..........
• Advanced Care
• or
• Palliative Care
• ........... to our Patients with Heart Failure?

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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 !!

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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

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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

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Our aim....

• To demonstrate that optimal care is cost
• saving...................

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Failures?
Diagnosis

• Routine management
• Advanced management

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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)

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New York Heart Association NYHA gt II Further
investigation required
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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

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NICE Guidance 2010
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Heart Failure Diagnostic Clinic One
stop Within 2 weeks
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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

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• HF referral poster
• AQ data

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Failures?
Diagnosis

• Advanced management

• Routine management

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Failures?
Diagnosis

• Advanced management

• Routine management

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Biventricular Pacemakers
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ECG

• P wave
• QRS duration

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Biventricular Pacemakers
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Biventricular Pacemakers
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Biventricular Pacemakers
36 reduction in All Cause Death / CVS death
/Hospitalisation
CARE HF Cleland et al, NEJM, 2005
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• Referral for CRT from North Lancs/ Blackpool

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Transplant vs. medical Rx
Butler et al. J Am Coll Cardiol, 2004
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Cardiopulmonary exercise testing
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Survival following cardiac transplant

• 1 year 85
• 5 years 73
• 10 years 58

www.uktransplant.org.uk
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Mechanical support Ventricular assist devices
Outflow Ao
Inflow LV/LA
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• Bridge to transplant
• Bridge to recovery
• Destination therapy
• Who should receive a VAD as bridge to transplant?

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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

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Thank you

• Any questions?