Naguib Hilmy GPSI Milton Keynes

John Parnell Manager Health:MK

ONS (2001); Cowie MR et al (2000) Heart 83: 505-510

www.heartstats.org

One-year survival rates, heart failure and major cancers compared,

mid-1990's, England and Wales

0 10 20 30 40 50 60 70 80 90 100

Cancer of the pancreas

Lung cancer

Cancer of the oesophagus

Stomach cancer

Leukaemia

Cancer of the kidney

Ovarian cancer

Heart failure

Colon cancer

Non-Hodgkins lymphoma

Cancer of the lip, mouth and pharynx

Prostate cancer

Bladder cancer

Cancer of the uterus

Breast cancer

Melanoma of skin

One year survival rate (%)

Ellis C et al (2001) Health Statistics Quarterly 11: 17-24

www.heartstats.org

Prevalence of heart failure by age and sex, most deprived and least deprived areas compared, 1998, England and Wales

0

50

100

150

200

250

45-54 55-64 65-74 75-84 85 and over Total

Age group

Pre

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per 1

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Most deprived (Q5)

Least deprived (Q1)

“Health: MK” is a practice based commissioning collaborative with 26 member practices and serving a population of >245,000 (total MK population >250,000).

MK Community cardiac service2 GPSIs, Admin, HCAs & Practice nurses

GPSI in North MK Dr Mahendran MKPCT CHD Lead

Support from MK NHS trust Cardiology Dr David Gwilt . Dr Attila Kardos

GP Referral Form MK Community Cardiac service

Signed by GP Print Name………………………………………………. Date ……………………………………

Please complete and return to: Dr Naguib Hilmy Whaddon House Surgery, 221 Whaddon Way, Bletchley, MK3 7EA 01908 272700 Fax01908 630076

Patient Details Patient Name ………………………………..Miss/Mrs/Ms/Mr NHS Number …………………………………. Address ……………………………………………………. Special Needs……………………………....... ………………………………………………………………. Date of Birth …………………………………… Post Code …………………………………… Tel no. …………………………………………. Mobile……………………………………………

GP Details [Stamp] GP Name …………………………………….. Tel no. ……………………….. Address ………………………………………. Fax no. ……………………….

Reasons for referral (Please be specific) Test&report only/ Test & advice Past Cardiac History: Hypertension MI Angioplasty/CABG AF Past Medical History: Diabetes Asthma Allergies COPD Medication:

Investigations Date Result Not Available

ECG

Hb

Sugar

Lipids TFTs

CCS workflow 2008

Paper, Fax , C&B

Cardiology OP Community Cardiac

Rehabilitation G.Ps

Triage by Admin & GPSI PCT

Database Red Book

Referral data entered on vision

Patient booked into clinic by telephone

Batch of letters passed to Admin for record keeping

Confirmation of appointment letter to patient + Information leaflets

HCA : ECG +Monitor / BNP Patient attends clinic, Clinical

assessment, ECG +/ Echocardiogram

Patient phoned to confirm attendance

Monitor /Echo reported & Summary letter to GP & Patient

Follow-up appointment

required

Patient discharged to care of GP and/or rehab

Referral to secondary care

Letters & Monitors attached to vision, Notes Filed

Clinic schedule produced for GPSI with referral letters/patient info

Reject referrals Phoned back/ Fax

to G.P

Patients on database 2558

Sept 08

24 Hour ECGs- Event recorders2008 4002007 3562006 2522005 1362004 49

RegistersHeart Failure Prevalence on 31/3/08

Practice Prevalence vs MKPCT and National Average

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

0.8%

0.9%

1.0%

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Practice Prevalence

National Prevalence

MKPCT Prevalence

North Central London sector-wide Heart failure QOF data National estimated prevalence: 2.3%National recorded prevalence: 1.8%

Heart Failure 2 (Echo)

Heart Failure 3 -ACEI

AuditPCT is providing help to practices to look at

their registers.

We have trialled a series of data audits and actions to pick-up missing and lost patients from the Heart Failure Registers. In both trial practices patients have been added to the registers.

The audits are being rolled out, either to be done by the practice or by PCT Heart Failure Nurse facilitator

RegistersChange in 2007 from implicit coding to

explicit, GPs or CHD nurse involvement now needed.

OPD letters rarely stated Heart Failure as a diagnosis.

Registration is geared to providing therapeutic management.

SupportThe process involves checking and advising

summarisers of the read code issues, and identify any learning issues for incorporation into training.

Heart Failure discussed with practice’s CHD nurse to ensure HF patients are seen. In this process we will also identify any training needs.

Updated Heart Failure Manual is being produced.

Heart Failure Rehabilitation ServiceA new service will start in May 2009 (probably)

which will provide exercise and psychological support for patients with a new diagnosis of Heart Failure.

Direct referral from GPs, Practice Nurses and MKFT.

Direct referral from HF Rehab to Community Cardiology Services.

With a pathway to provide long term self-care support.

Experience from initial searches at pilot practices

Until recently there was no universal definition for Heart Failure and a complicated system of read coding has evolved for QOF.

GMS QOF HF indicators include patients with - LVSD-LVDD

About half of the patients with measurable left ventricular dysfunction in the MONICA and ECHOES studies - had no symptoms.

Echocardiogram Data missing – ejection fractions and

ventricular function status.

For QOF purposes echo code needs to be linked to G58 codes.

Method of Case ReviewLoop Diuretics search (exclusions), problem

lists, medical history, current therapy, echocardiogram results if available.

Some empirical management of patients with symptoms, especially elderly patients.

Healthcare Commission found that nationally, only 33.4% of patients discharged with heart failure were prescribed beta-blockers and issues remain over follow up and titration of medication.  

LVD/ Heart Registers Access To diagnostics

Coding

Co-morbidities

Has the patient been given the diagnosis? “Weak Heart “ 'fluid on your lungs - your heart is

not pumping hard enough‘ “a diagnosis of 'heart failure' was rarely

communicated to patients to avoid causing anxiety”

Heart failure services in the UK – in figuresHeart failure services in the UK – in figures

16%16%proportion of GPs who have direct proportion of GPs who have direct access to echocardiography within access to echocardiography within

one monthone month

8%8%proportion of GPs who have access proportion of GPs who have access

through a specialist to through a specialist to echocardiography within one monthechocardiography within one month

22%22% GPs who never prescribe beta-GPs who never prescribe beta-blockersblockers

36% 36% GPs who always prescribe ACE GPs who always prescribe ACE inhibitorsinhibitors

Source: European Heart Journal, early online, 27 May 2008Source: European Heart Journal, early online, 27 May 2008

Heart Failure 1 (READ2)Heart Failure (G58%)Rheumatic Left ventricular failure (G1yz1)NYHA classification –class I (662f)NYHA classification- class II (662g)NYHA classification –class III (662h)NYHA classification- class IV (662i)

Codes not included as heart failureDilated cardiomyopathyIschaemic cadiomyopathyLeft ventricular systolic dysfunctionLeft ventricular diastolic dysfunction

Heart Failure 2 EchocardiographyEcho shows LVSD 585fEcho shows LVDDF

585gU-S heart scan 5853Echo abnormal 58531Echo equivocal 5C20Echo requested 33BDReferral for echo 8HQ7Echo abnormal R1320Ultrasound cardiog

abn R1322

Ref to cardio sp int gp 8H4R

Priv ref to cardiologist 8HVJCardiological referral 8H44Angiocardiography 5531, 5532, 5533,5538 79380, 79382

Should every body with suspected heart failure have an Echocardiogram?

How many?How often?

If investigation is limited to patients with more definite symptoms and signs of heart failure, fewer than 50% of cases will be identified and a large number of patients with mild symptoms will be missed EPICA

EPICAAbnormal ECG 81% sensitivity

Abnormal CXR 57% sensitivty

25% of CHF patients had normal ECG or CXR

Heart failure is most unlikely in a patient with a normal ECG or normal plasma concentration of BNP or NT-proBNP given the high sensitivity of these tests

The sensitivity of BNP may be as high as 90-97% in patients presenting with new symptoms , depending on assay used & cut off point

The sensitivity of ECG is as high as 94%

Tests used to diagnose significant CHD:

Treadmill test: sensitivity of 68%, specificity of 77%

Nuclear test: sensitivity of 81%, specificity of 85-95%

Portable Echo ( LVSD) : sensitivity 96%, specificity 98% NPV 99.6%

PSA for Prostate Cancer >4 sensitivity 70—79 %

specificity 59—90%

one in 8 men with PSA < 4 will have prostate cancer

Predictive ValueBNP (Biosite)

NPV 88.2% at 40pg/ml

Avoid 51 referrals – but miss 6 with LVSD

PPV 55% at 40pg/ml

NT pro-BNP (Roche)

NPV 97.3% at 150pg/ml

Avoid 37 referrals – miss 1 with mild LVSD

PPV 52% at 150pg/ml

What proportion of patients referred for suspected HF have heart failure ?

29 % Cowie 19995-8% in asymptomatic patients ?

Suspected Heart failureSOB , Fatigue, Oedema

Clinical assessment

NT-ProBNP ECG

NormalHeart failure

unlikely

AbnormalEchocardiogram

Murmurs Blackouts: Echo &

monitors

MK Community Cardiac Service Protocol for Heart Failure Diagnosis Patient name: Date: NHS number DOB Symptoms: SOB None(NYHA I) moderate exertion( II) mild exertion( III) At rest (IV) Orthopnea PND Fatigue Leg swelling Syncope Chest pain PMH : Hypertension Diabetes IHD Angina MI CABG Stent AF FH Examination: Pulse : Regular Irregular BP: Murmur: Oedema: Investigations: ECG: Normal Abnormal: old MI LVH LAD LBBB AF NT-Pro BNP: pg/ml Date:

Pasted from <http://www.diavant.com/diavant/CMSFront.html?pgid=1,10006,10006,1> Acute heart failure cut off point > 450 for patients < 50 years old > 900 for patients > 50 years old < 300 excludes acute destabilized heart failure IHD -adverse prognosis if persistent > 250 Cardioembolic stroke > 286 Diabetics -Higher risk > 160 Diastolic Dysfunction > 110 NYHA class I [97.5 pg/mL (77.2–120.6) vs. controls 55.7 pg/mL (32.7–86.3), NYHA class II [177.3 pg/mL (74.1–293.3) vs. 97.5 pg/mL (77.2–120.6), NYHA class III [334.7 pg/mL (180.2–976.8) vs. 177.3 pg/mL (74.1–293.3) In heart failure patients, each 100 pg/ml increase was associated with a 35% increase in the relative risk of death Pasted from <http://www.bmj.com/cgi/content/abstract/330/7492/625?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=diabetes+BNP&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT> Interpretation & Recommendations:

NT-proBNP levels in patients with reduced left ventricular function Median

Normal (n = 1,291)

56 pg/ml

NYHA I (n = 182)

342 pg/ml

NYHA II (n = 250)

951 pg/ml

NYHA III (n = 234)

1,571 pg/ml

NYHA IV (n = 35)

1,707 pg/ml

59 Males 59 Males Average Age 72 yearsAverage Age 72 years   44-97 , 8>85 Years44-97 , 8>85 Years41 Females 41 Females Average age 71 yearsAverage age 71 years   45-92 , 4>85 Years45-92 , 4>85 Years

        <60 pg/ml<60 pg/ml Female Female 77<60 pg/ml<60 pg/ml Male Male 141460-300 pg/ml60-300 pg/ml Female Female 191960-300 pg/ml60-300 pg/ml Male Male 2626300-500 pg/ml300-500 pg/ml Female Female 44

300-500 pg/ml 300-500 pg/ml Male Male 22500-1000 pg/ml500-1000 pg/ml Female Female 66500-1000 pg/ml500-1000 pg/ml Male Male 661000-3000 pg/ml1000-3000 pg/ml Female Female 441000-3000 pg/ml1000-3000 pg/ml Male Male 77>3000 pg/ml>3000 pg/ml Female Female 11>3000 pg/ml>3000 pg/ml Male Male 44

First 100 NT-ProBNP( Jan to June 08)

Results of less than 60 pg/ ml 21 patients

Results of less than 100pg/ml 37 patients

Results of less than 150pg/ml 39 patients

Results of less than 200 pg/ ml 54 patients

Results of less than 300 pg/ml 66 patients

Results of 300 to 500 pg/ ml 6 patients Results of 500 to 1000 pg/ ml 12 patients Results over 1000 pg/ml 16 patientsResults over 3000 pg/ml 5 patients

RESULTS

45/100 did not require a new or repeat Echocardiogram.

Heart failure with evidence of LVSD: eight patients.Heart failure due to diastolic dysfunction:

twelve patients.

16 patients with readings >1000 pg/ ml:

8 had LVSD, 3 LVDD, 3 Aortic stenosis, one had urgent AVR1 Significant MR

12 patients with readings between 500 & 1000 pg/ml

4 had diastolic dysfunction1 known heart failure with normal EF,

MV repair & AF

LVSD

EF 50% 388 & 2025 pg/mlEF 40% 1929 & 1468 pg/mlEF 30% 2435 , 2526 & > 3000

pg/mlEF 26% >3000 pg/ml

ECGs:

Normal: 51

Abnormal: 46

Not available: 3

Echos done 54

Normal ( 11 patients) levels (pg/ml): <60 x5, 60, 81, 165, 187, 278, 336

LVSD ( 8 patients ) levels (pg/ml): 388 (AF, EF 50%), 1468, 1929, 2025. 2435,

2526, > 3000 x2

LVDD with or without heart failure (12 patients) levels (pg/ml):

74, 92, 273, 293, 332, 513, 613, 680, 772, 1057, 1239, > 3000

20 patients Other abnormalities

including mitral regurgitation, aortic valve disease, small pericardial effusion, left ventricular hypertrophy etc:

Hospital referrals2 patients were admitted to hospital: one on

diagnosis & one with increasing symptoms

6 patients already attending cardiology

11 patients referred to cardiology: 3 AS, 1 MR, 1 PAF, 1 for pacing

45 Echos were not done or repeated6 were not repeated, One had been undertaken by hospital15 patients : COPD, asthma, chest infection 4 patients : advanced cancer Massive Ascites due to cirrhosis, panic

attacks, dementia , glitazone oedema

LimitationsThis is not an academic study: no blindingSome of these patients may not have been

referred to cardiology Some patients had previous echosPatients who had Echocardiogram followed

by NT-proBNP were included

Conclusions

NT-pro-BNP near patient testing combined with clinical assessment and ECG by PSI in the community appear to offer a method for prompt risk assessment for patients presenting with suspected heart failure

It helps to triage and prioritise patients that need immediate echocardiography and reassure those who do not require an echocardiogram and differentiate the ones that can have routine echocardiogram

We should continue to listen to our patients and not dismiss the value of careful clinical evaluation

Stage AStage A

At high risk, no At high risk, no structural structural

diseasedisease

Stage BStage B

Structural Structural heart disease, heart disease, asymptomaticasymptomatic

Stage DStage D

Refractory HF Refractory HF requiring requiring

specialized specialized interventionsinterventions

TherapyTherapy•Treat Treat

HypertensionHypertension•Treat lipid Treat lipid

disordersdisorders•Encourage Encourage

regular exerciseregular exercise•Discourage Discourage

alcohol intakealcohol intake•ACE inhibitionACE inhibition

TherapyTherapy•All measures All measures

under stage Aunder stage A•ACE inhibitors ACE inhibitors

in appropriate in appropriate patientspatients

•Beta-blockers in Beta-blockers in appropriate appropriate patientspatients

TherapyTherapy•All measures All measures

under stage Aunder stage A

Drugs:Drugs:•DiureticsDiuretics•ACE inhibitorsACE inhibitors•Beta-blockersBeta-blockers•DigitalisDigitalis•Dietary salt Dietary salt

restrictionrestriction

TherapyTherapy•All measures All measures

under stages under stages A,B, and CA,B, and C

•Mechanical Mechanical assist devicesassist devices

•Heart Heart transplantationtransplantation

•Continuous (not Continuous (not intermittent) IV intermittent) IV inotropic inotropic infusions for infusions for palliationpalliation

•Hospice careHospice care

Stage CStage C

Structural Structural heart disease heart disease

with with prior/current prior/current symptoms of symptoms of

HFHF

Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001Management of Chronic Heart Failure in the Adult, 2001

Problem solvingHarmful substances: -Smoking, Excess alcohol - Inappropriate type or dosing of B blocker - NSAIDS, Coxibs, Glitazones

Community Matrons, Heart Failure Nurses

http://depts.washington.edu/shfm/app.php?accept

=1&enter=Enter