Helen WilliamsConsultant Pharmacist for CVD South LondonClinical Lead for CVDLambeth and Southwark CCGs

Alison BentleyHeart Failure Specialist Nurse Croydon Health Services NHS Trust

www.nice.org.uk

NICE 2010 CG 108 Chronic Heart Failurehttp://www.nice.org.uk/CG108

And ivabradine….(NICE 2012)

www.nice.org.uk

Incremental Benefits with HF Therapies(Cumulative % Reduction in Odds of Death at 24 Months)

-28% to -49%P<0.0001

-54% to -71%P<0.0001

-68% to -81%P<0.0001

-75% to -86%P<0.0001

-77% to -88%P<0.0001

-72% to -87%P<0.0001

Fonarow GC, et al. J Am Heart Assoc. 2012;1:16-26.

Incremental Benefit with HF Therapies(Cumulative % Reduction in Odds of Death at 24 Months Associated with Sequential Treatments)

+20% to -68%P=0.1566

-43% to -91%P<0.0001

-70% to -96%P<0.0001

Fonarow GC, et al. J Am Heart Assoc. 2012;1:16-26.

www.gpcontract.co.uk

HF patients on ACEI = 22%HF patients on BB = 16%

People with chronic heart failure due to left ventricular systolic dysfunction are offered angiotensin-converting enzyme inhibitors (or angiotensin II receptor antagonists licensed for heart failure if there are intolerable side effects with angiotensin-converting enzyme inhibitors) and beta-blockers licensed for heart failure, which are gradually increased up to the optimal tolerated or target dose with monitoring after each increase

www.nice.org.uk

What are the barriers to ACEI and BB initiation?

What are the barriers to dose titration?

What additional support do GPs need?

People with chronic heart failure are offered personalised information, education, support and opportunities for discussion throughout their care to help them understand their condition and be involved in its management, if they wish.

www.nice.org.uk

Diet Salt intake Exercise Fluid restriction Alcohol Smoking Substance misuse Sexual activity Driving / air travel

Personal management plan

Heart failure traffic lights: http://www.cress.bics.nhs.uk/health-professionals/referral-support-directory/c/integrated-heart-failure-nurse-specialist-service/

Self manage diuretics

Access useful websites: BHF: www.bhf.org.uk ESC: www.heartfailurematters.org Cardiomyopathy Association: www.cardiomyopathy.org Arrhythmia Alliance: www.arrhythmiaalliance.org.uk

Limitations to uptitration:Beta-blockersSymptomatic

hypotensionBradycardiaEvidence of

reversible airways disease

Tiredness / fatigueWeight gain due to

increased congestion

Erectile dysfunction

ACE inhibitorsSymptomatic

hypotensionWorsening renal

function (increasing creatinine or potassium)

DizzinessPersistent,

intolerable dry cough that interferes with sleep - Uncommon

Case 1A 68 year old lady was seen 4 weeks ago by your

partner. She complained of increasing shortness of breath on doing

her daily housework. She had no past history of serious illness, and she had

oedema, a raised JVP and orthopnoea at night. Her BP was 140/90.

She was thought to have cardiac failure and was admitted because of a tachycardia. The hospital discharge note says she had CCF and was

discharged on: Aspirin lisinopril 2.5mg daily furosemide 40mg daily.

There is a follow-up hospital appointment in 6 weeks time.

QuestionsWhat more information would you like?

What should the GP’s follow-up management be?

Who else would you involve in this patient’s management?

Information…..ECHO results – EFECG – rate and rhythm and QRS durations

Admitted with a tachycardia (? No treatment!)NYHA classUnderlying cause

?ischaemia / ?hypertension / valve diseaseRenal function or dysfunctionBPAny relevant PMH on record

GP Management......1. Check BP, renal function, JVP / oedema2. Dose titrate ACEi at 2 weekly intervals3. Review diuretic dose4. Check HR – ?add a beta-blocker5. Lifestyle issues – salt, exercise, weight 6. If ischaemic cause – consider other CV risk

factors7. Check glucose – ensure no diabetes

Involvement of Others….Cardiology advice lineHFNSRelatives / carersPractice Nurse / community pharmacistDieticianRehab service (if available)Counsellor (if appropriate)Benefits / social services support (if

appropriate)Local cardiac support group

Case Study 2A 63 year old male was being followed up in

the heart failure clinic. He complained of breathlessness on mild exertion.

He was taking the following medications: Frusemide 80 mg odRamipril 10 mg odSpironolactone 25 mg odBisprolol 10 mg od Aspirin 75 mg od.

On examination the heart rate was 90 per minute and regular.

The blood pressure measured 86/60 mm Hg. The JVP was raised. The cardiac apex was

displaced. Auscultation of the heart revealed an added

third heart sound. The chest was clear. There was no ankle odema.

Echocardiography showed a dilated left ventricle with an ejection fraction of 25%.

Question……Which one of the following would you institute to

improve his symptoms?Refer for cardiac transplantation Add Hydralazine Increase the dose of loop diuretic Increase spironolactone Refer for ?ICD Refer for ?biventricular pacemaker

Case Study 3JJ DOB: 04.03.1940 Cardiac / Heart Failure

History Dilated cardiomyopathy of ischaemic aetiology. 06.01.04 Echo:

LV severely dilated, global hypokinesis / function severely reduced. RV – severely reduced function. EF = 25- 35%

Mild MR – why might this patient have MR? how should it be managed?

Other Medical HistoryAsthma since childhood, severe airflow obstruction, Chronic

obstructive airways disease - 4 yr history Right carotid endartrectomy 1996 Impaired fasting glucose, reviewed in diabetic dept who

advise diabetic diet and 6 monthly HbA1c Angina

Main problems are:pain in knees limiting mobilityinability to lose weight but felt that the diet

outlined by dietician was not achievable not sleeping well

He is not aware of palpitations, no pre syncope, uses 1 pillow but often sleeps in chair, no PND.

On examination - JVP normal, no cardiac heave, pulse of normal and character, no dependent oedema, no respiratory crackles.

NYHA class III (unable to determine how much is heart failure related)

HR 92 bpm; BP 127/82; Weight 117.2 kg

Current Medication…..Ramipril 5mg bdFrusemide 80mg omSpironolactone 25mg

dailyAspirin 75mg dailySimvastatin 40mg onIsosorbide mononitrate

MR 60mg omGTN sprayAtrovent FormoterolFluticasoneSalbutamol inhalers

Any comments on his drug therapy?

Would you consider a beta-blocker for him?

This man is complaining of ‘nipple pain’ what is the likely cause? What would you do about it?

How would you manage this patients arthritis?

What lifestyle issues would you consider for him?

Other primary care interventions to reduce his risks?

How can you help him sleep?

ACE InhibitorsACE Inhibitors

Reduce mortality in HF by ~ 25 to 30%• CONSENSUS-I, VeHFt-II, SOLVD, GISSI-3, AIRE

Initiate early in the disease in pts:– With or without symptoms of LV dysfunction– With reduced Ejection Fraction on ECHO (<40%)– Benefit established across all NYHA classes

Optimise dose (ATLAS) Continue indefinitely

Managing ACE inhibitor therapyStart at low dose to avoid first dose hypotensionIncrease dose to maximum tolerated

i.e. Rampril 10mg daily, lisinopril 20mg twice daily

Monitor renal function and potassium Advise low K+ diet if potassium high

Monitor BP - but can increase dose if sBP ≤ 90mmHgSymptomatic hypotension may limit dose titration

Common side effects – cough, hypotension, rash

Beta-Blockers~30% reduction in mortality (additive to ACE-I)

Reduction in hopsitalisationsUS Carvedilol Trials, MERIT-HF, CIBIS-II,

COPERNICUS

Data in NYHA class II, III & IV HFInitiate in all patients with LV dysfunction -

regardless of whether or not symptoms persistIntroduce in a ‘start low, go slow’ manner, assessing

HR, BP and clinical status after dose titration

Withdrawal of beta-blockers has been shown to: increase risk of worsening heart failure increased risk of early death

Circulation 1989; 80, 551-563; AmHeartJ 1999; 137, 456 - 459

Offer BBs to….older adults patients with:

peripheral vascular diseaseerectile dysfunctiondiabetes mellitusinterstitial pulmonary disease andchronic obstructive pulmonary disease

(COPD)

Beyond ACEI and BB… Add Aldosterone antagonist?

Mortality benefits evident in clinical trials but generally sicker patients – EF<30% in EMPHASIS HF and recent hosp admission

Multiple studies across the patient spectrum

Add ivabradine? Reduces hospitalisations and HF deaths in pts in sinus

rhythm if HR remains raised; despite optimal BB BUT, only one study to support......)

ARB? Main effect in RCTs was reduced hospitalisations

Add hydralazine/nitrates? Mortality benefits in African Americans NYHA class

III, but poorly tolerated and heavy pill burden

EMPHASIS HF(eplerenone)

Using Aldosterone Antagonists Dosing:

25mg daily initiallyIncrease to 50mg daily if remains

symptomaticReduce to 12.5mg daily if hyperkalaemia

Key ADRsHyperkalaemia (common esp with ACEI)GynaecomastiaRenal deterioration

Drug withdrawal common

1. Andrews TC et al .Circulation 1993;88:92-100 / 2. Ho JE et al. TNT study - poster presented at the ACC 58th Annual Scientific Session, March 29-31, 2009. / 3. Fox K et al. Lancet 2008; 372: 817-821 4/ Cardiovascular continuum adapted from Dzau et al. Circulation December 2006

Heart Rate & Coronary Heart DiseaseHeart Rate & Coronary Heart Disease

major cardiovascular events 2

in patients with stable CHD

major cardiovascular events 2

in patients with stable CHD

hospitalisation for fatal or non-fatal MI 3

in patients with CAD and LVD

hospitalisation for fatal or non-fatal MI 3

in patients with CAD and LVD

+37% RR+37% RR

+38% RR+38% RR

+46% RR+46% RR

+34% RR+34% RR

heart rate > 70 bpmheart rate > 70 bpm

A number of studies have shown that patients with A number of studies have shown that patients with

have increased risk of:have increased risk of:Coronory Atherosclerosis

Coronory Atherosclerosis

Coronary Artery Disease

Coronary Artery Disease

Myocardial Ischaemia

(Stable angina)

Myocardial Ischaemia

(Stable angina)

MyocardialInfarction

MyocardialInfarction

Left Ventricular Dysfunction

Left Ventricular Dysfunction

Chronic Heart Failure

Chronic Heart Failure

cardiovascular death 3

in patients with CAD and LVD

cardiovascular death 3

in patients with CAD and LVD

likelihood of ischemia 1

in patients with stable coronary disease

likelihood of ischemia 1

in patients with stable coronary disease

Ivabradine – heart rate controlSHIFT study (2010);

6558 patients with resting HR > 70bpm randomised to ivabradine or placebo

Primary end-point - CV death or HF hospitalisation

Reduction in the primary end point from 29% placebo to 24% Ivabradine arm – an 18% relative risk reduction (ARR 5%, p<0.0001)

Mostly due to reduced HF hospitalisation and deaths due to HF

HF due to LVSDStandard RegimenDiuretics (for symptom control)ACE Inhibitors to improve outcomeBeta-blockers to improve outcome+/- Spironolactone if more severe HF (Class III/IV)Or eplerenone if less severe HF (class II)(Or candesartan?)Ivabradine if HR remains >75bpm (licensed

Jan 2012?)

Other Issues

PolypharmacyMultiple therapiesCo-morbidities

Non-adherenceSymptom control vs risk reductionIntentional vs non-intentionalHealth beliefs

Helen WilliamsConsultant Pharmacist for CVD South LondonClinical Lead for CVDLambeth and Southwark CCGs

Alison BentleyHeart Failure Specialist NurseCroydon Health Services NHS Trust