Heart Failure

1
Heart Failure

• Patients with chronic heart failure tend to have
  an extremely poor quality of life and a
  prognostic outlook that is comparable to many
  forms of cancer

2

• Heart failure management is a gradual and
  overlapping progression from active through
  palliation to terminal care
• It does not always require a sudden treatment
  change as active measures are often an aid to
  patient comfort.
• Ward (2002)

3
Definition/diagnosis

• Heart failure is a clinical syndrome caused by a
  reduction in the hearts ability to pump blood
  effectively around the body, causing a series of
  Heamodynamic,renal, neural and hormonal
  responses.

4
Incidence/Prevalence

• 1-2 of population
• 5 of all hospital admissions (166.2 million
  cost)
• Mortality of 30 in 12 months
• Mortality of 50 in 3 years
• 3-20 people per 1000 have heart failure
• 80 people per 1000 among gt75
• 11000 new cases per year
• 101000 new cases per yeargt85s and over
• Stewart
  2002

5
Causes

• Myocardial infarction
• Valve disease
• Hypertension
• Atrial fibrillation
• Cardiomyopathy(dilated,viral,alcoholic)

6
Presenting Symptoms

• Breathlessness
• Oedema
• Lethargy
• Orthopnoea
• Reduced exercise capacity

7
Pathophysiology

• Poor LV function
• Decreased cardiac output
• Neurohormonal response
• Activation of sympathetic renin angiotensin
• Nervous system aldosterone system

8

• Angiotensin II vasoconstriction
• Aldesterone sodium fluid
• retention
• Further stress on LV wall
• Further worsening of LV function
  

9
Medication

• Ace inhibitor-ramipril,lisinopril,perindopril,enal
  april
• 36reduction in mortality in 1yr(Consensus)
• Beta blocker (bisoprolol, carvedolol)
• 32 reduction in morality (CIBIS II 2000)
• Diuretics( loop, potassium sparing)
• 30 reduction in mortality in NYHA 4
  (Rales )

10
Education

• Cause definition
• Symptom monitoring-breathing, oedema, pillows,
  daily weight
• Medications
• Lifestyle-smoking, alcohol, salt intake,
  exercise, vaccinations
• Booklets

11
ICDs and heart failure

• Implantable cardiac defibrillator
• Recommended by NICE guidelines post MI plus EF lt
  35 and specific electrophysiological criteria
• Cardiac arrest triggers repeat discharge
• QOL effected (anxiety, lifestyle issues)
• Deactivation needs to be discussed in advanced
  disease

12
Biventricular pacing

• Appropriate for only a small group
• Can improves functional capacity and QOL in some
  cases
• Limited use at present due to technical difficult
  and specialist centres

13
Advanced physical symptom symptoms

• NYHA 4
• Severe oedema
• Abdominal discomfort
• Cardiac cachexia
• Cognitive impairment
• Marked hypotension
• Insomnia

14
Dying from heart failureMcCarthy M et al 1996

• Symptom () Final Year
• Pain 78
• Dyspnoea 61
• Cough 29
• Mental disturbance 59
• Insomnia 30
• Anxiety 43

15
Trajectory for dying

• Key Heart Failure
• Lung Cancer

16
Managing breathlessness

• Caused by alveoli oedema, perfusion
  mismatch,peripheral resistance
• Oxygen
• Exclude underlying causes
• Posture/comfort
• Adapting living e.g. moving bed, rearranging
  shelves
• Relaxation/deep breathing exercises
• Or morph at night
• OT/Physio input

17
Managing fatigue

• Causes are dehydration, anaemia,
  infection/malabsorption, cardiac cachexia
• Assess nutritional state
• Refer to dietician
• Daily activity planning/pacing
• Establish sleep pattern
• Comfort measures
• Exercise /rehab
• Treat depression

18
Managing oedema

• Good skin care
• Diuretics
• Limb warmth
• Weight monitoring
• Adequate dressings for oozing
• Practical footwear
• Supporting body image changes

19
Pain

• Can present as abdominal discomfort due to
  hepatic congestion, thigh pain due to reduced
  cardiac output and muscle wasting
• Seek specialist palliative care advice
• Avoid ibuprofen , muscle rub creams contain
  ibuprofen
• analgesia pain ladder

20
Psycho-social issues

• Anxiety
• Depression
• Loneliness and social isolation
• Carer exhaustion
• Financial worries
• Body image and sexuality

21
Communication issues

• Understanding of illness
• When to seek help/call doctor
• Idea of what the future holds
• What about resuscitation
• Hospital revolving door
• Am I dying?
• Do we know our patients wishes regarding aim of
  care?

22
Possible Prognostic markers

• Marked Left Ventricular dysfunction
• Arrythmia
• Hormonal assays (ANP, rennin)
• Low sodium
• Frequent hospitalisations/HF reviews
• Worsening oedema
• Progressive renal failure

23
When to use the Gold Standards Framework for HF
patients?CHD collaborative suggest 2 or more of
the following criteria

• Severe symptoms both physical or psychological,
  despite optimal treatment
• Worsening intractable oedema
• Cardiac cachexia
• 3 admissions to hospital within the last 12
  months with symptoms of heart failure despite
  optimal medication
• Would you be surprised if this patient died
  within the next 12 month?
• Joanne Lynn Director Centre to improve Care of
  the Dying

24
When do heart failure nurses refer to specialist
palliative care?

• Failing to control physical symptoms
• Complex emotional/social needs
• Social isolation
• Practical support to allow dying at home
• Cares with high risk of bereavement difficulties

25
Improving Care

• Shared care between services
• Timely progressive move towards supportive
  terminal care
• Access to expertise of palliative care team
• Good communication/honesty
• Training for HF nurses and cardiologists and GPs
• Access to hospice/day hospice services

26
Moving forward

• Heart failure nurses are encouraged to form
  close working relationships with specialist
  palliative care providers in order to learn about
  the expertise and services available NHS
  modernisation agency (2004)

27
Finally

• It is unrealistic to expect the wider emerging
  needs for palliative care to be met by expanding
  the workforce of specialists in palliative care.
  It is more likely that a solution will be found
  by expanding the knowledge and skills of health
  professionals generally.
• WHO (2004)

28
references

• Supportive and palliative care for advanced heart
  failure
• Coronary heart disease collaborative
• www.modern.nhs.uk/chd
• NICE heart failure guidelines 2004
• www.nice.org.uk
• National service Framework for Coronary Heart
  Disease (2000)
• Gold Standards Framework
• www.goldstandarsdframework.nhs.uk