cardiology - ipswich and east suffolk ccg

Presented by:

Dr Paul Bethell GP Lead for Planned Care

16th April 2015

Cardiology

IHT •6 consultants

- all with specialist areas

•PCI

•CoW – rapid access for advice

Integrated Community Cardiology Service

•Consultant–led •GP •Nurse

(seeing 20% of current outpatients)

•Triage of referrals – 10% advice only needed

•Timely and local access – max 6 week from referral

•Letter and management plan within 5 working days

Primary Care •Education Programme

•Local Cardiology Pathways (Atrial Fibrillation, Palpitations, Syncope, Heart Failure, Murmurs, Chest

Pain/Stable Angina)

•Pre-Referral Guidelines to avoid delay and duplication

•Access to diagnostics – Echo, BNP, 24 hour ECG, Rapid ECG Analysis, ABPM

•Telephone Advice (COW)

•Map of Medicine with standard info leaflets and links to useful websites

Self Care and Prevention •Patient Involvement •Condition Leaflets •Website Information •Support Groups (Heartbeat)

Car

diol

ogy

Clin

ical

Net

wor

k co

ntin

ue to

m

onito

r and

impr

ove

syst

em

Integrated Cardiology Service for

Ipswich and East Suffolk CCG

Review medications - Increase diuretics and start /increase Ace/ARB (unless contraindicated)

Very elevated NT -pro BNP

(>2000pg/ml)

If unknown to either Ipswich hospital or Community Heart Failure team refer for advice or appt

Worsening symptoms & signs suggestive of heart failure

Request NT-proBNP +FBC, U&Es, LFT’s, TFT’s glucose, INR, ECG, CXR

If known to Ipswich hospital or

Community Heart Failure team contact

them to discuss / review.

Echo if not done within last 12 months & repeat echo if new onset of; • Ischaemia (post MI) • AF/ other arrhythmia • Murmurs/ suspected valvular disease • Previously good LV function

Abnormal echo

GP to assess severity

Assess for other causes of

Breathlessness

Normal echo (Discuss with

cardiology if heart failure strongly

suspected)

If clinically unwell admit to Ipswich

hospital

Low NT-pro BNP (<400pg/ ml)

Intermediate NT-pro BNP (400-2000pg/

ml)

Ipswich Hospital & Ipswich & East Suffolk CCG – Previous Diagnosis of Heart Failure in Primary Care Final (V6.0 April 2015)

This pathway differs from NICE guidelines but local

adaptions have been agreed.

Moderate/Severe LVSD on Echo

Significant Valve disease

• Heart failure – not palliative • HF with preserved EF on echo • Heart failure not responding to NICE guidelines • Ongoing cardiology investigations • Aetiology of heart failure unknown • Device management • Significant valve disease Refer to Ipswich Hospital Heart Failure clinic

• Optimisation of medical management • Palliative care / house bound • Known aetiology • HF with preserved LV function diagnosed by

cardiology Refer to Community Heart Failure team

6 w

eeks

• Mild LVSD on Echo

• No severe valve disease

• Known cause of HF

• GP confident

Primary care conservative/medical

management (Discuss with Ipswich Hospital Heart Failure clinic if needed)

Max

2 w

eek

wai

t

GP to manage while awaiting BNP result initiate loop & ACE + ARB unless contra indicated

Very elevated NT -pro BNP

(>2000pg/ml)

Refer to Hospital Heart Failure clinic

Signs and symptoms suggestive of heart failure.

Request NT-proBNP +FBC, U&Es, LFT’s, TFT’s glucose,

INR, ECG, CXR

Refer for Community Echo

Abnormal echo

GP to assess severity

Primary care conservative/medical

management (Discuss with Hospital Heart

Failure clinic if required)

Moderate/Severe LVSD on Echo

Significant Valve Disease

Assess for other causes of

Breathlessness

Normal echo (Discuss with Cardiology if Heart Failure

strongly suspected)

Low NT-pro BNP (<400pg/ ml)

Intermediate NT-pro BNP (400-2000pg/

ml)

Ipswich Hospital & Ipswich & East Suffolk CCG – New Diagnosis of Heart Failure in Primary Care Final (V6.0 April 2015)

If clinically unwell admit to Acute hospital admission

Max

2 w

eek

wai

t

This pathway differs from NICE guidelines but local

adaptions have been agreed.

• Mild LVSD on Echo

• Clear underlying cause of HF

• GP confident

• Optimisation of medical management

• Frailty issues (mobility/housebound/palliative)

• Refer to Community heart failure team

• Heart failure – not palliative • HF with preserved EF on echo • Aetiology of heart failure

unknown • Device management • Significant valve disease Refer to Hospital Heart Failure clinic

Start treatment Initiate loop diuretic

6 w

eeks

Our Passion, Your Care.

The role of NT-proBNP in Heart Failure

Sanjay Jeyaseelan MD MRCP Consultant Cardiologist

Ipswich Hospital


Presentation

• Background • Physiology • Uses of NT-proBNP • Case discussions • Conclusions • Questions


Heart Failure

• Common condition with high morbidity and mortality.

• Leads to hospital admissions and readmissions • Can be difficult to diagnose • Evidence based treatment available for heart

failure which help improves symptoms, prognosis and reduces hospital admissions


Symptoms and Signs of Heart Failure

• Typical symptoms: Dyspnoea, Fatigue, Oedema

• Typical signs: Raised JVP, Displaced Apex Beat, Gallop Rhythm, Crepitations, Effusions, Hepatomegaly, Ascites, and Oedema


NICE Chronic Heart Failure Guidelines

• Chronic heart failure: management of chronic heart failure in adults in primary and secondary care

• Clinical guidelines, CG108 - Issued: August 2010

• http://www.nice.org.uk/CG108


Key steps for better HF outcomes

• Early and accurate diagnosis • Mechanism of heart failure

• Prompt and appropriate treatment • Optimising treatment • Monitoring


NICE HF cost savings per 100, 000 patients using BNP


Heart Failure costs

• In 2002, £716 million (1.8% of total NHS budget)

• Hospital in-patient stay £250 per day • Echocardiography £60 • Cardiology out-patient £160

• NT-proBNP £20


Heart Failure Pyramid


HF treatment available for East Suffolk

• Advice & Support: Heart Failure & Rehab team

• Medication: Diuretics, ACE inhibitors, ARBs, B-blockers , Aldosterone antagonists, Digoxin, Ivabradine, Hydralazine, Nitrates • Devices: ICD, CRT-P, CRT-D


HF treatment available for East Suffolk

Cardiac Intervention and Surgery: PCI, CABG, Valvular Surgery Advanced Heart Failure: Inotropes, Haemo-filtration, LVAD, Artificial Heart, Transplant End stage Heart Failure: Palliative care


The heart as an endocrine organ

• An endocrine organ secrete hormones directly into the circulatory system to be carried towards a distant target organ

• Natriuretic Peptides released by the heart • Causes vasodilatation, diuresis and sodium

excretion • Pro Atrial Natriuretic Peptide • Pro Brain Natriuretic Peptide


BNP and NT-proBNP


Brain Natriuretic Peptide

• Released by the ventricular myocardium in response to increased intracardiac volume and/or pressure

• BNP secretion controlled at the transcription level so sustained stimulus is required

• Causes include LVSD, volume overload, LVH, and ischaemia

• BNP levels increase with age and renal failure


Brain Natriuretic Peptide

• BNP levels higher than normal in patients with HF

• BNP levels decrease with diuretics and ACE Inhibitors.

• BNP levels initially increase with B-Blockers and then decrease.

• BNP levels decrease with spironolactone and ARBs


Diagnosing HF with BNP

In one study a NT proBNP of 300pg/ml: Sensitivity 94% Specificity 61% Positive Predictive Value 44% Negative Predictive Value 97% Therefore an excellent “rule out” test Improves diagnostic accuracy


HF prognosis and monitoring with BNP

• Higher the BNP levels the worse the prognosis. Helps identifies patients at most concern.

• BNP levels fall as HF treated. Levels can be rechecked for exacerbations of HF.


HF Clinical Evaluation

History: • To formulate diagnosis and to monitor

response to treatment • Age, Gender, Ethnicity,

Symptoms (inc. Duration and Severity), PMH of IHD or HTN, Respiratory Disease, Medication, Allergies, Smoker? Alcohol?, Family history of IHD or Cardiomyopathy


Aetiology of Heart Failure

• Heart Failure can occur due to many different causes.

• Identification of the cause guides treatment.


Causes of Heart Failure

• Ischaemic heart disease (most common cause) • Hypertensive heart disease • Cardiomyopathy (Dilated, Hypertrophic,

Restrictive, Peripartum) • Valvular heart disease • Congenital Heart Disease • Arrhythmia


Causes of Heart Failure

• Viral and other infection (Chagas disease) • Alcohol and Drugs • Chronic lung disease (Cor

Pulmonale/Pulmonary Hypertension) • Pericardial Disease • Hyperdynamic Circulation disease (Anaemia,

Thyrotoxicosis, AV malformations) • Connective Tissue Disease


Medical Treatment of LVSD HF

Loop Diuretics: Improve symptoms •Frusemide and Bumetanide ACE inhibitors: Improves symptoms and prognosis. Maximise dose •Ramipril, Perindopril, Lisinopril ARBs: Improves symptoms and prognosis. Maximise dose. •Candesartan, Losartan, Valsartan B-Blockers: Improves symptoms and prognosis. Maximise dose. •Bisoprolol, Carvedilol, Nebivolol, and Metoprolol CR/XL


Medical Treatment of LVSD HF

• Spironolactone and Eplerenone: Improves symptoms and prognosis.

• Hydralazine and Nitrate: Improves symptoms and prognosis. Up-titrate dose. In place of ACE inhibitors/ARBs in Renal Failure

• Ivabradine: Reduces Hospitalisation. In Sinus rhythm >70/min and B-blocker intolerant/insufficient.

• Digoxin: Reduces Hospitalisation. In Sinus rhythm or AF and B-blocker intolerant/insufficient.


Classification of HF symptom severity

New York Heart Association(Little, Brown & Co; 1994) • Class 1: previous symptoms now no

limitation with ordinary activity, • Class 2: slight limitation with activity, • Class 3: marked limitation with activity, • Class 4: symptoms at rest or unable to

carry out any activity without symptoms.


Treatment of LVSD HF in NYHA Class 1

• Beta blockers (Metoprolol, Carvedilol, Bisoprolol, Nebivolol),

• ACE inhibitors, and Angiotensin receptor blockers (Candesartan, Losartan, and Valsartan).

• Maximise beta blocker and ACE inhibitor to highest tolerated dose .(Heart rate >55, Blood pressure >90mmHg systolic)



• Loop Diuretics, • Beta blockers, • ACE inhibitors, ARBs, • Eplerenone (EF<30%), • Digoxin • Ivabradine (EF<35%, HR>70, sinus), • ICD (EF<35%), • CRT-D (EF<35% & QRS>120ms),



• Loop Diuretics, • Beta blockers, • ACE inhibitors, ARBs, • Spironolactone (EF<35%), • Digoxin, • Metolazone, Hydralazine and Nitrate, • ICD (EF<35%), CRT-D (EF<35% &

QRS>120ms),



• Loop Diuretics, • Beta blockers, • ACE inhibitors, ARBs, • Spironolactone (EF<35%), • Digoxin, • Metolazone, Hydralazine and Nitrate (EF<35%), • CRT-P (EF<35% & QRS>120ms), • (Inotropes, LVAD, Artificial Heart, Heart

Transplant) • Palliative Care


Heart Failure Pyramid


Case Discussion 1

70 y.o. Male. Previous MI. Type 2 DM (Diet). SOB on 100 yards last 2 months Rx: Aspirin & Simvastatin Pulse 76, BP 140/70, HS: Normal Chest: Bilat. Creps. JVP: Elevated, Oedema of Ankles Plan?


Case Discussion 2

• 25 y.o. Male. Normally fit & well • Flu illness 1 month ago • Progressive SOB & now at rest too • No medication • Pulse 120, BP 85 systolic, HS: Gallop,

Chest: Dull bases, JVP: Elevated, Legs: no oedema

• Plan?


Case Discussion 3

• 80 y.o. Female. Known HF. HTN. CKD 2 • SOB on exertion for 1 year , now breathless on

little exertion. • Rx: Frusemide 40mg & Ramipril 2.5mg • Pulse 80, BP 150/70, HS: Normal, Chest: Dull

bases, JVP: difficult, Legs: Oedema up to knees • Plan?


Case Discussion 4

• 68 y.o. Male. Bronchiectasis & HTN • SOB for 2 years. SOB worse last week. Has

cough • Rx: Inhalers, Carbocisteine and Amlodipine • Pulse 100, BP 130/80, HS normal, Chest:

Bilateral Creps and Wheeze, Legs: mild oedema • Plan?


Case Discussion 5

• 54 y.o Male. COPD. Alcohol 40u/week • SOB and Palpitations for 2 months • Rx: Inhalers prn • Pulse 120 irregular, BP 140/80, HS normal,

Chest: Basal Crepitations, JVP raised, Legs: ankle oedema

• NT-proBNP 1500 • Plan?


Case Discussion 6

• 70 y.o Female. Overweight but otherwise well

• Increasing Breathlessness over 6 weeks. • Pulse 100, BP 120/70, HS: normal, Chest:

Clear, JVP: elevated, Legs: no oedema



Case Discussion 7

• 36 y.o African origin Female. Asthma. FH of DCM. 6 months Post Partum. Breast feeding.

• SOB despite using inhalers regularly • Pulse 100, BP 100 systolic, HS: normal, Chest:

Bilateral Crepitations, JVP: difficult, Legs: no oedema



Case Discussion 8

• 69 y.o Female. Hypothyroid. New to practice • SOB and tiredness 6 months • Rx: Thyroxine • Pulse 100, BP 110/70, HS: ESM, Chest:

Crepitations in bases, Legs: no oedema • NT-proBNP 2500 • Echo: Moderate LVSD, Suggestion of Severe

AS • Plan?


Case Discussion 9

• 85 y.o Male. Lives in RH, mobilises with Frame, HTN, Type 2 DM, CKD 3,

• SOB and oedema • Rx: Bendrofluazide & Metformin • Pulse 80, BP 160/90, HS normal, JVP raised,

Chest: Dull bases, Legs oedematous • NT-proBNP: 1900 • Echo: Normal LV systolic function, Mild AS, Mild

MR • Plan?


Case Discussion 10

• 57 y.o. Male Previous CABG, Known HF, new to Practice. Had problems with gynaecomastia in the past

• SOB on exertion but plays Golf • Rx: Frusemide 40mg, Ramipril 5mg, Bisoprolol 1.25mg • Pulse 76, BP 96/50, HS normal, Chest clear, JVP normal ,

Legs, no oedema • NT-proBNP 600 • ECG SR 75/min LBBB, normal PR • Echo: Severe LVSD, Mild MR • Plan?


Conclusions

• Identify Heart Failure patients early • Establish cause of HF • Educate patient • Start treatment as soon as possible • Maximise treatment • Monitor patients


Questions?

cardiology - ipswich and east suffolk ccg

Documents