Heart Failure Protocol (Read Code G580)

Heart Failure protocol

These guidelines apply to those with reduced LV ejection fraction or LV systolic dysfunction. In patients with preserved ejection fraction >50%,or diastolic heart failure, the evidence base for treatment remains unclear.

Risk factors

Age > 65, IHD, HT, AF, valvular heart disease, renal failure, anaemia, thyrotoxicosis, myocarditis and cardiomyopathy.

Diagnosis of suspected Heart failure.

If previous MI – refer within 2 weeks (NICE CG 108 2010 Chronic heart failure)

If no previous MI – check BNP:

1.  100-400: refer* within 6w.

2.  > 400: refer* within 2w.

3.  Normal <100 : consider other diagnosis.

Other causes of a raised BNP = LVH, ischaemia, tachycardia, RV overload, hypoxaemia (inc. PE), GFR <60, sepsis, diabetes, COPD, age >70 and liver cirrhosis.

Beware, BNP levels are reduced by heart failure treatment such as ACE, diuretics and betablockers)

*Refer = refer cardiology and Echo.

Then, evaluate further:

ECG.

Consider, CXR

Bloods (creatinine, electrolytes, eGFR, TFT, lipids, glycoHb, FBC.

Note ESR raised in HF so CRP used to detect inflammation

Urinalysis.

Peak flow or spirometry.

. .

Ensure they have the ‘CCF’ G58..% Read code once the diagnosis has been confirmed with Echo and promote to major active problem.

NB: If confirmed LV systolic dysfunction, add ADDITIONAL code (see below)

New York Heart Association Classification

Grade Read Symptoms Mortality at 12 months

I 662F No limitation of normal activity

II 662G Some limitation of normal activity 15%

III 662H Severe limitation of normal activity 30%

IV 662I SOB at rest 60%

Indications for referral

1.  Initial diagnosis.

2.  Managing severe HF (NYHA class IV), HF not responding to treatment , HF due to valve disease or HF which can no longer be managed at home.

3.  Pregnant or preconception.

Treatment

1. PROGNOSIS improvement in LVSD.

NB: code LVSD if diagnosed, as well as CCF/HF: XaJ98 and XaIIq.

(see QOF : HF 003 and 004 – those patients with HF due to LVSD the % currently treated with and ACEI – or ARB . And the % of those patients who are additionally treated with a BB)

·  First line treatment; both ACE inhibitors and, Betablockers; titrated to maximal tolerated doses.

·  Second line treatment – seek specialist advice (NICE).

Consider add – Aldosterone antagonist or,

-  ARB or,

-  Hydralazine with nitrate

·  Third line treatment – specialist.

Consider - cardiac resynchronisation +/-

-  Pacing +/-

-  Digoxin and,

Consider – Ivabradine (see below).

NOTE:

CI and relative CI to ACE = CR > 150, K > 5.5, angioedema, renal artery stenosis, significant aortic stenosis (refer in these situations). CAUTION in women of childbearing age and contraindicated if trying to conceive or pregnant.

ACE inhibitors - Starting regime for Primary Care derived from the HOPE study regime and BNF guidelines.

If creatinine &Es pre treatment reveal a creatinine < 150 micromol/l and a sodium >130 mmol/l then 2.5mg Ramipril daily (1.25mg if on concomitant diuretics) for one week with check creatinine &Es and an increase to 5.0mg Ramipril for a further three weeks. Re-check creatinine &Es 1 week after each dose increment and attempt to up titrate all patients to the 10mg dose. Thereafter repeat creatinine Es on an annual basis.

If patient is unable to tolerate ACE inhibitors try an ARB e.g. Candesartan (CHARM study showed that they reduce mortality in patients unable to tolerate ACE inhibitors).

Beta blockers - In addition to normal treatment patients with NYHA grade I, II and III HF should have a trial of a betablocker e.g. bisoprolol (CAPRICORN STUDY – Grade 1, Merit-HF trial – Grades II and III) as this decreases mortality and hospital admissions.

This should include patients with COPD, PVD, diabetes and ED. The three betablockers shown to convey most advantage are carvedilol, bisoprolol and metoprolol.

Bisoprolol starting regime ( consider referral to Heart Failure Specialist Nurse if available).

Week 1 2 3 5 8 12

Bisoprolol (mg) 1.25 2.5 3.75 5.0 7.5 10

NB Consider back dose titration if the patient develops symptomatic hypotension, asymptomatic systolic BP < 90mmHg, bradycardia < 50bpm or respiratory symptoms.

Bisoprolol is not contraindicated in COPD but should be added cautiously.

Ivabradine is indicated if:

-  NYHA class II-IV stable chronic HF

-  Pulse 75 or more, sinus rhythm.

-  Taking standard therapy inc. BB, ACEI and aldosterone antagonists *OR when BB is CI or not tolerated.

-  LV ejection fraction 35% or less.

*Only after 4 weeks stabilisation period on standard therapy.

Should be initiated by specialist or in association with HF specialist nurse.

Cardiac resynchronisation is indicated if all the following apply:

-  Current (or recent) NYHA III and IV symptoms.

-  In sinus rhythm.

-  QRS duration of 150ms or longer on ECG or QRS 120-149ms on ECG and dyssynchrony confirmed on Echo.

-  Ejection fraction 35% or less.

-  On optimal drug treatment.

.

Eplerenone. Patients with acute MI & LVD benefit from Eplerenone (an aldosterone antagonist) post MI, so you may see some patients discharged on this.

2. SYMPTOM RELIEF in all causes of heart failure.

- Loop diuretics

Diuretics are used to reduce fluid overload (oedema and pulmonary congestion) and may be reduced/stopped once on established HF treatment.

Tips for increasing furosemide doses

40mg to 80mg in the morning

80mg to 80mg in the morning & 40mg at lunchtime

80mg in the morning & 40mg at lunchtime to 80mg in the morning and 80mg at lunchtime

- Digoxin, oral morphine, s.l. lorazepam etc.

- Rehabilitation.

Offer supervised, exercise based rehab programme (if available) for HF patients if stable (care with eg. high energy pacing device).

Should include psychological and educational elements.

Co-prescribing

Try to avoid NSAIDs, COX II inhibitors, Diltiazem, Tricyclics, Corticosteroids and effervescent preparations e.g. eff. Solpadol, as these have a high sodium content.

Annual review:

At annual medication review you should ensure they have had:

·  Updated NYHA classification

·  Smoking status/cessation advice

·  Alcohol intake and advice

·  BMI

·  Pulse – rate and rhythm

·  BP

·  Bloods as per table within the last 12 months (HF alone = creatinine and electrolytes, eGFR, HBA1C, lipids if not on statin)

·  Offer rehab if appropriate

·  Annual flu vaccination irrespective of age and Pneumovax if none previously

THE PATIENT PATHWAY

Patients, as a result of remembering their annual review date or having a reminder on their prescription will ring to book their annual review. The reception team will book non fasting morning bloods & BP appointment with HCA.

The HCA will review the patient’s co-morbidities using the SystmOne chronic disease icons page (checking for COPD, Asthma, HT, IHD/TIA/CVA) to decide the tests they have to perform. They will also arrange a 20 minute review with a Practice Nurse ( 30 minute appointment if they also have asthma, COPD or a history of MI, angina, TIA or stroke).

The Practice nurse, on completing the annual review, where no action is deemed to be necessary, will also document and inform the patient of their next planned review date and task the appropriate GP to code the medication review and reauthorise the prescriptions. Review care plan and record Read code using template if patient is on Case Management Register.

Patients requiring further assessment or a change in medication will be referred to the GP.

Useful Patient Information Booklet = BHF booklet on heart failure http://www.bhf.org.uk/heart-health/living-with-a-heart-condition/living-with-heart-failure.aspx

Palliative care

Consider discussion of palliative care and formal coding, listing as problem in record, handover form, DNACPR discussion/form and patients preferred place for care if active secondary care no longer appropriate. Consider case management and care plan under 2014 Hospital admission avoidance DES.

QOF 2014-2014 (no changes from last year)

HF 001 The practice establishes and maintains a register of patients with heart failure 4 points

HF 002 Percentage of patients with heart failure (from 01/04/06) confirmed by echocardiogram or by specialist assessment from 3/12 before to 12/12 after diagnosis

HF 003 Percentage of patients with left ventricular dysfunction currently treated with ACEI/ARB 10 points threshold 60-100%

HF 004 Percentage of patients with left ventricular dysfunction currently treated with ACEI/ARB and betablock 10 points threshold 40-65%

Sources:

Chronic Heart Failure – NICE 2010.

http://www.nice.org.uk/nicemedia/live/13099/50526/50526.pdf

Ivabradine for treating CHF – NICE 2012.

Cardiac resynchronization therapy for the treatment of heart failure – NICE 2007.

BW June 2014

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